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HomeMy WebLinkAbout2024-00065735 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 MOO 0111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03588698 u, 1 U21 1 1 1 U, 7 U2 1 U, 1 1_12 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00065735 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ❑Y ®N 10 14 2024 ❑AM ❑YES ®NO U1 -< RANDALL RD Elgin04:55 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m 1 O !MI N E S VY HO S Rd COUNTY PROPERTY ❑Y ® N DOORING ❑v #OF MOTOR 0 SLOW 15 u) ® pp Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 4 n 0 5 ! yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S 4 COM VEH 0 j$J 1 O F. ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; _-5 *II Yes.See Sidebar U1 Z EC11490 IL 2025 TELEPHONE IL D 0 JTHBA30G945051945 Horace Mann ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Chavez.Gerson. I. 63000873740101 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 KCV 0 DV !1 9 yf 7 Chevrolet Equinox 2019 00-NONE 1U-� t2 c,�2 FIRE DUE OCRASH 0 ® U2 2 C o 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S --4 COM VEH D ® ut CO FIRST CONTACT 6 O7 ,�=Q 05 •IfYes.SeeSidebar C Z Carpentersville IL 60110 0 1 0 BB62033 IL 2024aR 0 Si) D IL D 0 3G NAXU EV8KS508148 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 976537251 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 10(14 l2024 04 55 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 0 28 03 ( ( 0 PM ❑Construction >E R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o1El 11 1 ARREST NAME Chavez. Benjamin. N. 11-601-Ax S1526000255 ( ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM r 2 El ARREST NAME 10(14 l2024 04 55 ®PM El Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 45 1526-Walsh.Jacob 702 334-Fries 11 (26(2024 01 30 ®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 ----r•---, , ; 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 INDICATE NORTH combination):or —I ' I r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I _ (example:shuttle or charter bus):or ' I I 3. Is desgned to carry 15 or fewer passengers and operated by a contract career O } -- i } } } transporting employees in the course of their employment(example:employee I I transporter-usually a van type vehicle or passenger car):or w i. <.__-a__-_� _-_-- --.--_ •4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, ' I. Pe ( P 9 Pe or L L--_-a--- s - t i. i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D . placarding(example:placards will be displayed on the vehicle). XI —I • CARRIER NAME Z wrmnrma ADDRESS 02 1 CITY/STATE/ZIP T. n rnrAaaar 1 � g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ----1 - USDOT NO. ILCC NO. rn XI Source of above Z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. _Redmons/Impound Lot Garage . 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