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HomeMy WebLinkAbout2024-00063860 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii 1110111111 III 101011100 IHO HO III 1011010111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035,93E2 u, 1 U210 1 1 1 U199 U2 1 U, 1 U2 1 U,99 U2 1 1 9 u1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ID ON SCENE 1 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063860 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg m ELM ST ® ❑ Elgin RELATED ❑Y co" 10 06 2024 03:30 ❑AM ❑YES ®No u1 ,-< PRIVATE mo /day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑" DOORING ❑y #OF MOTOR ❑SLOW 15 N ❑ FT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 -I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ❑ N PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 . Unknown Unknown Unknown DO-NONE 11 1s i' , DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El 21 U2 0 m SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 = .1- ❑Y ❑N ®UNK VEH. AT CRASH ®INT UNKNOWN 6 II 6 I( COM VIER ion�� 0 ® ALGN1 OF CITY PLATE NO. STATE YEAR } m F ID VIN INSURANCE CO. EXPIRED 1 o UNKNOWN Unknown ❑Y ❑N U2 I- m M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Same Unknown 1 r r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU .5 ❑Y ® Same" 99 0 0 DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NlAV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Porsche Macan 2021 oo-NONE 11 12 , 1 DUE roCRASH ❑ ® 1 73 13-UNDER CARRIAGE 10 I ! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPCA 1 a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value 9 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �5 II ll 4 COM VEH 0 ® U1 to 1- FIRST CONTACT 7 5 5 •It ves,See Sidebar C EG26687 IL 2025 i REAR 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 WP1AA2A5XMLB08815 GEICO ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I FLEMING-REDMON. KIMBERLY. E_ 4241440280 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 122 CANTON LN .Streamwood, I L.60107 (773)510-7239 U1 = (UNIT) (SEAT) ;DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)[(ADDRESS)/(TELEPHONE) {EMS) (HOSPITAL) n I I U2 996 1— m / / - - '#OcCS > / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 18 5 10,06 ,2024 08 00 0 pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 C) T 2 0 18 18 ! / 0 PM ❑Construction * c' 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 5 Q 1 ® 11 5 ARREST NAME / / ❑PM C]Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8AM 10 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? ❑Y 10 537-Sanders, Richard 701 334-Fries , , ❑PM ®N U2 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. (ripIF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS iVot7b Scefe ; __ _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } 1 i i __ I ; ; combination)or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` } ', , i ` r r r (example.shuttle or charter bus)-or X designedcarryor fe passengersand operatedr 0 } } theirXI _� +saaa,ns„�a- 1 f : transportingporter employees a van type vehicleorpass passenger ce)t oample.employee rie C contract car �o1 �____A____: : i , `__ ' I i I. r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, fn .� for direct compensation(example:large van used for specific purpose).or O L____-L____4 . .. �_ ------ i } i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' — — t ADDRESS 0 ------_-_—_-_-------- —;------------_ ;:.. .;: , . _ — -/ O CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ElIntrastate 0 Not in Comm./Govt. El Not in Comm./Other r_ -'-_ , i z • r USDOT NO. ILCC NO. m XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown M Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown 0 C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C Z Form Number D m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z ip Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO: SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE