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HomeMy WebLinkAbout2024-00063799 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III OII III 1III1011 lIOfl IHO MIII IM 1111011 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY n035793/2' u, 1 U21 1 1 1 U1 5 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 2 El NOT ON SVEHICLE/PROPERTY ill OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063799 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 N STATE ST El ❑ Elgin RELATED ❑Y coN 10 06 2024 03'56 DAM ❑YES ®No u1 ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m 2340 ® 'COUNTY PROPERTY El ®N DOORING 0 y #OF MOTOR ❑SLOW 2 f/) /MI N E S W Frazier Ave 'WITH VEHICLES INVLD ElSTOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NMV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) 0 3 / 2 0 J 2 0 0 4 FOR DAMAGEDAREA(S) FROM TOWED U1 mo day yr 1$ C.) 13-UNDERCARRIAGE • FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 53 U2 4 m 525 N CLIFTON AVE M ❑Y ®SYsNEM❑UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 16-TOP 3 •Distraction Value 9 ALGN I r CITY PLATE NO. STATE YEAR POINT OF 8 6 4 COM VEH 0 ® 1 O A ~ 2G1WG5E30D1132779 American Alliance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same I LAA-0965702-00 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU 73 L ❑Y ®N 2 G) ®DRIVER El PARKED 0 DRNERLESS El PED ❑PEDAL El EQUES 0 WVElNCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m FOR DAMAGED AREA(S) FRO TOWED Y N 5 NAME(LAST,FIRST,M) Gabriel.Arminda. R. 12 /mo 1 Jd 6 1 9 7 NT yray 8 Dodge Ram 1500(pickup) 2022 00-NONE 1t` ©i'_1 DUE TO CRASH ❑ ® 2Xi 13-UNDER CARRIAGE 10 1? Y FIRE ❑ 21 U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPCA C) a` 3449 W 61 ST 2 F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y Igl N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7_'1 a 1_S C•IOMe6VSee Sidebar❑ ® U1 to PEAR C Z Chicago IL 60629 0 3458566B IL 2022 0 (p D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)664-7343 G164-0007-8957 IL D 0 1C6RRFFG8NN411958 Allstate ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 811 626 286 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNITE (SEAT) iDOBi (SEX) ISAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL) 1 3 03 /20/2002 F 2 3 0 1 0 Chloe L. Sensor/85 JERUSHA AVE•ELGIN-IL.60123 Refused 996 ,- (224)828-1172 , U2 m / / #OCCS D / /• u1 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z N ® 11 1 10/06 /2024 04 10 0 pm in a Work Zone? ®N DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C) T 2 0 06 28 ! I 0 PM El Construction * N T 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 QU2 ARREST NAME Bridges. Riley.J. 11-601-Ax 1537-004(VI/) / / ❑❑AM El Maintenance SLMT U , CO 11 1 ®CITATIONS ISSUED ❑PENDING • TIME 0 Utility SLMT o N SECTION CITATION NO. ROAD CLEARANCE AM 35 2 0 ARREST NAME Bridges. Riley.J. 11-801-A 1537-003 10/06 /2024 04 00 El RA0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 1537-Mapp•Teddron 501 334-Fries 11 / 12,2024 09 00 0 RA Workers present? ®N U2 35 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. _ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS _r } A CMV is defined as any motor vehicle used to transport passengers or property and. Z r.rw., 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer -< r I I i combination) or INDICATE NORTH XI — — BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', d i / -` ` r r r (example'.shuttle or charter bus)-or 0 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----% -t t - i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w : . r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N ® for direct compensation(example large van used for specific purpose) or O -: y 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 11 """""""`r m placarding(example placards will be displayed on the vehicle) Z1 CARRIER NAME Z • ' �s1 ADDRESS 0, � ' ' �_ - iI I - CITY/STATE/ZIP • MOTOR CARR ID ❑ Interstate ❑ Intrastate I 0 ' ( • 0 Not in Comm./Govt. El Not in Comm./Other _ Not To SC,Je ' : USDOT NO. ILCC NO. XI , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? O ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 M 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Red Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE