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HomeMy WebLinkAbout2024-00064236 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets ii ii III 010 �1 101011100 1110 1111 III 111 11E1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O3579680- u, 1 U21 1 1 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 1 U2 3 *P 0119* 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 ®ON SCENE 2 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00064236 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 '17 N MCLEAN BLVD El In ID ❑Y coN 10 08 2024 12'08 ❑AM ❑YES ®NO U1 .< g PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ID SLOW 1 U) ElFT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER 0 PARKED 0 DRIVERLESS ❑ PED O PEDAL ❑EOUES ❑SIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) FRONT TOWED Ut O NAME(LAST,FIRST,M) . M. mo 1 2 / a 2 y yr 8 J 1 9 9 9 General MotorSiQrirff 00-NONE 11 O� 1 DUE TO CRASH ❑ (21 13-UNDERCARRIAGE 10i I 2 FIRE ❑ ® 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m 10165 CO M PTO N DR M ❑Y ®SNEM❑UNK VINEH. O AET CRASHD 0 99-UUNKNOWN THER 9 16-TOP 3 ,Oistractlon Value 6 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 I� 4 COM VEH ❑ ® 1 O F FIRST CONTACT 12 7_. e l�_5 •li Yes,See Sidebar U1 Z Country Mutual ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 99 9 Schroeder Asphalt Se AV9181578 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r L RESPONDER Y°®EN PO BOX 831 - Huntley- IL.60142 (815)923-4380 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 98 m m 1 / J FOR DAMAGED AREA(S) Fi20 IT TOWED Y N NAME(LAST,FIRST,MI Hoepfner, Nicholas-W. lmo 1 aay 1 9$2 Chevrolet Chevelle 1965 oo-NONE 11, 12 '_s DUE TO CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X a 4N330 ANDERSON RD M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j ) 4 COM VEH ❑ ® U1 to F FIRST CONTACT 6 7__•_1 ;_5 •If Yes,See Sidebar Elburn IL 60119 0 77252EA IL 2025 fop 0 C 2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)715-2469 H 156-6398-2324 IL D 0 137375G 111884 Country Financial ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 9 Same P12A8219884 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°ON Same U1 = (UNIT) ;SEAT) (DOBi (SEX) ;SAFT) (AIR) (INJi (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'/-4ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) - 2 3 1 0 /1 0/1989 M 2 4 0 1 0 Andre Mello Bepe/62 TALL GRASS CT,STREAMWOOD,IL.60107 Refused 996 ,- (224)266-8244 , U2 m / / #OCCS D / / u1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N1 ® 11 1 10,08 /2024 12 18 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C) T 2 ❑ 03 40 ! / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 • Q CO 11 1 ARREST NAME Lucius,Jeffrey, M. 11-710-A W499000719 / / ❑PM SLMT o U ❑CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility N 8 AM 45I 2 ❑ ARREST NAME / / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El Y 45 499-Dirck Cameron 602 272-Bajak / / ❑PM ®N U2 I 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 ' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z r-"--r----, , 4 r r r r r , , , 1 . r 0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer -< ' r i ; i i i- r r , , i r 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 ', ! (- t L ' ' '. ', ' l' ` 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 Hated to trans rt between 9 and 15 assen ers including the dr ver, 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 . ` 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 r•---, r - DO ILCC NO. m U N XI , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 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 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 White BlackEn - 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