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ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003579&49-
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away
Elgin Police Department ONE PERSON'S ®$501-$1.500 ID ON SCENE 7
[23 NOT ON S
VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00063964 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N SPRING ST ® ❑
Elgin RELATED ❑Y coN 10 07 2024 10_29 ®AM ❑YES ®NO u1 ,•<
PRIVATE mo /day I yr ID PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR CI SLOW 3 Cl)
❑ FT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —1
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NW ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 10 0
,Jennifer, E. 0 5 / 1 0 /1 9 5 8 Toyota Prius FOR DAMAGEDAREA(S) FRONT TOWED U1
2007 00-NONE 11 12 y,DUE TO CRASH ElNAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 fil
1 1 Y FIRE ❑ ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m
158 S CHAN N I N G ST F ❑Y ®SNEM❑UNK VINEH. 0 AET CRASHD 0 99-UUNKNOWN THER 9 16-TOP 3 ,Distraction Value 9 ALGN =
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CITY PLATE NO. STATE YEAR POINT OF 8 i1 _ i 4 COMVEH ❑ ® 1 F FIRST CONTACT 1 7_: 6__,• 5 "If Yes,See Sidebar U1
0
m
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JTDKB20U677576548 American Family ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Same BX10562609 1
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
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m ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED 0 PEON. 0 EOUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1
Y N m
m / / FOR DAMAGED AREA(S) FRONT TOWED
n NAME(LAST,FIRST,M) mo day yr Mazda MAZDA5 2012 00-NONE 11 ` 12 ,_� DUE TO CRASH ❑ ® 98 x1
c 13-UNDER CARRIAGE 10 I I I 2 FIRE ❑ ® U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 ❑ El SPDR X
❑Y ® N 'DUNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value 9 U1 0
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1II I COM VEH ❑ ® C
F FIRST CONTACT 9 7_.1 a ._5 •It Yes,See Sidebar
BL43413 IL REAR 0 fp
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
J M 1 CW2DL5C0138987 Sentry ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 Hawks Auto 4470460001 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
1480 ABBOTT DR. ELGIN . IL.60123 (847)697-3050 U1 =
iUNIT1 (SEAT) iDOBi (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)U(TELEPHONEI (EMSt (HOSPITAL)
2 1 10 /1 1 /1946 M 1 3 0 1 Larry D. Annis/38W073 HOPI LN.Elgin.IL.60124 996 r
(847)431-5856 - U2 m
/ / #OcCS y
/ / U1 1 m
/ I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z
N 1 ® 18 5 10,07 /2024 10 39 ❑pM in a Work Zone? El DIRP co
1 rJ• I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 C)
T 2 ❑ 11 99
! / 0 PM ElConstruction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance uz
Q 1 ® 11 5 ARREST NAME / / ❑PM• E]Utility SLMT
0 U 0 CITATIONS ISSUED ❑PENDING SECTION I CITATION NO. ROAD CLEARANCE TIME
',3N 8AM 10
2 0 ARREST NAME , / 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-Hometer,William 272-Bajak , / ❑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.
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
: l : l : 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
' r • ; i ; i- r r , , i INDICATE NORTH combination).or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' L ', ', ! i. L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or n
S
; 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 7,
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
placarding(example placards will be displayed on the vehicle) 11
T.
. `
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP
. • - MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r ,-•---, ir - DO ILCC NO. m
U N Xl
, • • Source of above Z
•
. ❑ Yes 0 No ❑ Unknown A
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 C
z
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
m
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Red White
-
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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