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HomeMy WebLinkAbout2024-00065657 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIII lull 11111111111111111 IIIII11111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035B9346 u, 9 U2 1 1 9 U1 99 U2 U199 U2 U1 99 U2 1 4 9 U199 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE0 NOT ON 1 VEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00065657 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 'r1 STEWART AVE ❑Elgin RELATED ❑Y co" 10 14 2024 0924 ®AM ❑YES ®NO U1 .‹ PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y M N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ❑ FT/MI NESW Cook HIT&RUN ®Y ❑ N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 D4 ORNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U, 0 .0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH ❑ ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 .r 2 FIRE ❑ IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN 8 4 'Distraction Value ALGN .. r CITY PLATE NO. STATE YEAR POINT OF II 6 I(_ COM VEH 0 IZI 1 0 I— FIRST UNK El ❑N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 1 99 9 Same UNK 9 r d1 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER RESPONDER VEHU X •o Refused ❑Y ®N 9 Same 99 GI m ❑DRIVER ® PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 RUV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED —1 Honda Civic 2017 00-NONE it i'_1 DUETOCRASH ❑ ® 1 NAME(LAST,FIRST,M) mo day yr 10 or 2 FIRE ❑ ® U2 C c t3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 9 X a ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value POINT OF 6 it 4 U1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR { 6 COM VEH ❑ ® to 1— FIRST CONTACT 12 7-r 5 •ItYes,See Sidebar DE58185 IL 2025 Rom. O cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 9XFC2F7XH E206950 STATE FARM ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I CORNEJO.SERGIO.A. 0883961SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 765 STEWART AVE. [LOIN . IL•60120 (847)894-3186 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (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 / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 18 9 10/14 /2024 09 24 ❑pM in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 0 T 2 0 28 99 ! / 0 PM ElConstruction * r' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 AM ❑Maintenance uz Q 1 ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 0 ARREST NAME i I pti1 ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID, COURT DATE TIME 2 2 3 0 ❑AM Workers present? ElY 25 374 Rizzu o. Michael 201 275-Engelke , 0 PM El 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS Not 7b Scale illjo _ } 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 r 1 i 1 INDICATE NORTH combination) or —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. d i -` ` r r r (example.shuttle or charter bus)-or n X CM - designed passengers operated contract rer 0 i-- - -;----- + ,R,,,,K 1. i' transpon employees the course theiremployent(example employee M transporter-usually a van type vehicle or passenger car).or (p :____A____: : i , : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I ) cm' for direct compensation(example:large van used for specific purpose).or L____—____4 4 ; , : i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI CARRIER NAME Z ' t ADDRESS 0 N . • CITY/STATE/ZIP 2 MOTOR CARR ID ❑ Interstate ❑ Intrastate r , 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. , Source of above Z • If Yes Name on placard O 4 digit UN NO. 1 digit Hazard class No M 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash% fl ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 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 ft Z Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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