HomeMy WebLinkAbout2024-00064457 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003581446
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00064457 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
® ❑ RELATED ®Y 0 N 10 09 2024 ®AM ❑YES ®NO U1 -<
S MCLEAN BLVD Elgin09:51
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W RT20 EB COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 Mlles 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y
N 9
NAME{LAST,FIRST,M) EN 9 0FOR DAMAGEDAREA(S) FROM T TOWED U1
HEATWOLE. FRAN KLI N. L. 0 4 /
yr 13-UNDER CARRIAGE 10l ! FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 99 171
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER O9 16-TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _Dail� �'.4 COM VEH 0 j$J 1 n
F. FIRST CONTACT 9 7_ 6--_;__5 *uves.See Sidebar U1 0
Z DECKER MI 48426 0 1 0 EVH6157 MI 2024
TELEPHONE
MI Other STDXZ3DC2JS946819 AUTO-OWNERS INSURANCE CO. ❑Y ®N U2 m
IF. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 4780717900 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER eu
g DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NOV 0 Nev 0 DV
!1 9 8 0 Honda Pilot 2016 00-NONE ,i � t20, DUE TO CRASH p 2
0 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 1l, COM VEH ❑ ® U1 to
FIRST CONTACT 1 7�. -5 •If Yes.See Sidebar
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STREAMWOOD IL 60107 0 1 A928999 IL 2025 REAR
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IL D 0 SFNYF6H51 G B033363 AAA ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
HEMSOUVAN.CHANTHAVIS AUT700878721 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused 0 Y°ND
0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
1 3 04 / F 2 4 0 1 0
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 4 10,09 r2024 09 51 0 AM rgi in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
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2 20 99 r r 0 PM 0 Construction *
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME HEATWOLE. FRAN KLI N. L. 11-709-A W244-1782 r r El PM SLMT
o N 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
❑ 30
t 2 El ARREST NAME AM
7 r r ❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
244-Blomberg. Michael 701 272-Bajak r r ❑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.
• A CMV is defined as for vehicle used to transportand:
r ----,5-••--, ; any motor passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }----i-- --; } } } r -, , ; ; , ; ( combination):or -I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i } ' i 1 , } (example:shuttle or charter bus):or
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3. Is
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e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or 03
< <.__-a-_-_- , i• < <--_-a-_--- 1 , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..i.____� l. i i • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zj
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CARRIER NAME Z
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ADDRESS 0
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CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
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❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
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USDOT NO. ILCC NO. m
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Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Whitew
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE