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HomeMy WebLinkAbout2024-00066359 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II 111111111111111111H1 1101011 1111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003590625 u, 9 uz 1 1 1 9 U199 uz 1 U199 U2 1 U1 99 U2 1 9 9 U, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY El OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066359 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 MISSION HILLS DR El El ❑Y coN lO 17 2024 11:13 ®AM ❑YES ®No U1 .-‹ PRIVATE mo /day/yr El PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ®SLOW 1 U1 ❑ FT/MI N E S W 'WITH VEHICLES INVLD 0 STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y El 11' PEDALCYCUST®N 0 FREE FLOW # LNS 0 D4 ORNER 0 PARKED ❑ERNERLESS ❑ FED 0 PEDAL ❑EOUES 0 NW ❑NCv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE IA 10 1 ,r 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 ® U2 2 m r / ❑Y ❑N ❑UNK VEH. AT CRASH . POINT OFO 8 it i-4 V 0 ®Distraction Value ALGN CITY PLATE NO. STATE YEAR } 6 i COM EH4 m I- ID VIN INSURANCE CO. EXPIRED 4 unknown ❑Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a r 99 9 Same unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU -Er Same 99 0 ❑DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) mo day yr Hyundai Elantra 2017 00-NONE 1 y DUE TO CRASH ❑ ® 2 c 13-UNDER CARRIAGE O:j 12 !_2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) A': SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN 8 4 •OistractIonValue g U1 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® C FIRST CONTACT 11 7__.1II 8_5 •(ryes,See Sidebar ZU39489 IL 2024 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KMHD84LF6HU381290 GEICO ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Monohan- Matthew 4577105523 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 1806 MISSION HILLS DR. ELGIN . IL.60123 (224)280-1497 U1 = (UNIT( (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS(((TELEPHONEI t EMS) (HOSPITAL) n I I U2 996 r m / / - #OCCS y / /• U1 1 m 11* / 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 10,17 /2024 11 14 ❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 C) T 2 ❑ 18 18 ! / 0 PM ❑Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 30 2 0 ARREST NAME 1 / pti1 ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 326-Hornsby. Marc 700 272-Bajak , / ❑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____; ; ; _r Q} A CMV is defined as any motor vehicle used to transport passengers or property and. ZD r } ; combination) or 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< ; INDICATE NORTH —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` } I I d i -` ` r r r (example'.shuttle or charter bus)-or 0 END 0<____a____. 4 , : : } itransportingdesigned emplo eeslin[hecouseoftheiremployment(example�emaployeecarrier 3 Is '�806 f transporter-usually a van type vehicle or passenger car).or w ""_"......__"' ' ' Not To Scale I ! i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) for direct compensation(example:large van used for specific purpose).or O L_____-____; iany: } i 5 Is any vehicle used to transport hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) n O` CARRIER NAME Z ' ADDRESS 0 N Mission?Hills?Drive • CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate . . 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . 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? ID Yes No ❑ Unknown 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 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o 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 © Unknown VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE