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HomeMy WebLinkAbout2024-00063956 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets ii ii III 010 �1 101011100 1110 1111 III 1011111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY x003579656' u, 1 U2 1 1 1 U, 9 U2 1 ut 1 U2 U1 99 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE • 7 [23 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063956 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m RT20 El ❑ Elgin RELATED ❑Y coN 10 07 2024 09:00 ®AM El YES ®No U1 .( PRIVATE mo /day I yr El PM FLOW CONDITION m COUNTY PROPERTY -.Y ❑N DOORING 0 y #OF MOTOR ❑SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD ElSTOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IZ N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑CRNERLESS ❑ FED ❑PEDAL ❑EOUES ❑NIA/ ❑NCV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n . Miuel1 2ayyr FOR DAMAGEDAREA(S) FRONT TOWED U, 0 NAME(LAST,FIRST,M) g mo 0 / a 9 /1 9 8 2 Chevrolet C/K 3500 1998 -NONE 11 12 , DUE TO CRASH 0 21 ,3-UNDER CARRIAGE ��1• 2 FIRE ❑ IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 519 STAN D I S H ST M ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 76-TOP 3 .Distraction Value 9 ALGN 2 CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH 0 El 1 0 a ~ 1 G BKC34J 1 WF054132 Progressive ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 981999569 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU L ❑Y ❑N Same 99 0 ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL 0 EQUES 0 NMV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) fi20 IT TOWED Y N NAME(LAST,FIRST,M) mo day yr Audi A5 2023 00-NONE tt 12 y DUE TO CRASH 0 ® 2 -I c 13-UNDER CARRIAGE 10 I I: Y FIRE ❑ MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 ® SPDR n ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 - POINT OF COM VEH N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR g 0 ® to 1— FIRST CONTACT 6 7___5 •It Yes,See Sidebar EC18876 IL I_ O cCn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 WAU FACF5OPA029513 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Rodriguez Barrera- Maria K496898F2613A BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 576 S STATE ST. ELGIN . IL.60123 (847)702-8266 Ut = (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 r m / / - #OCCS D / /• U1 1 m 19 / 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 10/07 /2024 09 20 ❑pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 1 C) T 2 ❑ 18 18 ! / 0 PM El Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q 1 ® 11 5 ARREST NAME / / 0 PM 0 Utility SLMT 0 U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ',3N 8AM 10 2 0 ARREST NAME I / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 10 547-Homeler,William 272-Bajak I / ❑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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I 0 ADDITIONAL UNITS FORMS . ' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! i- ._ ' ' '. ', ' I. ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - 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 desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , Source of above Z . ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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