HomeMy WebLinkAbout2024-00064008 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00064008 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '17
RT20 WB ❑Elgin RELATED ❑Y coN 10 07 2024 01:30 ❑AM ❑YES ®NO U1 ,-<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
®10 ®I MI N E S® GRACE St 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW CD
Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 0 1 n
Jeep FOR DAMAGEDAREA(S) FROM TOWED Ul
DIJETOCRASH
NAME(LAST,FIRST,M) ,AM IAYAH.O. mo / day J yr (after 198) ade 2020 00-NONE a g 0 OD D El ❑
13-UNDERCARRIAGE FIRE ❑ ®
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SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 10 U2 m
2208 TELEGRAPH RD F SYTM❑Y ®SNE❑UNK VEH. O AT CRASH D O 15-99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN I
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T. CITY PLATE NO. STATE YEAR POINT OF 6 it 6 .• 4 COMVEH 0 ® 1 n
FIRST CONTACT 1 7 t •_-5 "IfYes,See Sidebar U1 O
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ZACNJBBB4LPL32466 BRISTOL WEST ®Y ❑N U2 m
B
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a' 99 9 Same G01444314600 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU X
L ❑Y ®N 2 0
m 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑RCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
a, / J FOR DAMAGED AREA(S) fi20 IT TOWED
fi ' 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
c 13-UNDER CARRIAGE 101 2 FIRE ❑ ❑ 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 0 SPOR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •DistractionValue U1 0 -
POINT OF03
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.-- .-5 a I_5 CIO VEH
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H R • C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID V1N INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 10 I
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
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(UNIT) I SEAT) iDOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAMEi/t ADDRESS i(i TELEPHONE' (EMS) (HOSPITAL) C)
1 4 09 /08/2020 F 2 5 0 1 0 KENNEDY WINTERS/2208 TELEGRAPH RD,DAVENPORT.IA.52804 I—
(319)304-0091 U2 m
1 3 01 /1 0/2001 F 2 5 0 1 0 TONYA RICKETTE/815 OAKCREST ST. IOWA CITY-IA-52246 '#OCCS D
(319)621-7783 _
/ / U1 03 m
/ I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z
N 1 ® 20 1 10/07 /2024 02 00 0 PM in a Work Zone? ®N DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 7
T 2 0 99 99
! , 0 PM El Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / El PM SLMT
o U 1 ❑Utility
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8AM 55
2 0 ARREST NAME 1 / ptil ❑Unknown work zone type Ut
T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
El
1506-Nunez. Maria 401 334-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.
0( ) F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
; '� _i A CMV is defined as any motor vehicle used to transport passengers or property and. D
4 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r } 1 i I Nor ro Ebou 1 ; ; INDICATE NORTH combination) or
XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} J. ', ', i �1 -! ` r r r (example.shuttle or charter bus)-or X
----?-----� 4 -! } idesigned
employeeslin the course of theirem and
operated
(example�emaployeerier M 3 Is
../.00 j`._ f : transportingnsporter-usuall a van type vehicle or passenger car).or 03
C
4
�____A____: : , _ d : i r I- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, fn
Z for direct compensation(example.large van used for specific purpose).or O
___; ; . 1 i } i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example placards will be displayed on the vehicle) 71
T.
���'������/� CARRIER NAME Z
' ADDRESS 0
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CITY/STATE/ZIP
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MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
'
r , USDOT NO. ILCC NO.
XI
, Source of above Z
. If Yes, Name on placard o
4 digit UN NO. 1 digit Hazard class No
73
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 D
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 ❑ No -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number D
m
X1
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
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Gray
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑,r DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons 1 Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO.
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE