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HomeMy WebLinkAbout2024-00066444 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III 010 III 11111 ll 1111111111111111101111111111 IIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E441 u, 1 U21 1 1 1 U1 8 U2 1 U, 1 U2 1 Ut 1 U2 1 1 12 U1 13 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00066444 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 't'I DOUGLAS AVE ® ❑ Elgin RELATED ❑Y coN 10 17 2024 05:47 ❑AM ❑YES ®No u1 ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 5 Cl) 050 ®/MI N O s w East ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EOUES 0 ram 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRO Na TOWED Ut O .S. 0 8 / 1 1 J 1 9 7 0 Hyundai Tucson 2018 00-NONE 11 12 i' 1 DUETOCRASH ❑ 21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10)• .r 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I U2 2 m 2768 VILLAGE GREEN DR B4 M SY 15-OTHER ❑Y ®SNEM IN ENGAGED❑UNK VEH. n AT CRASH O 99-UNKNOWN 016 3 .Distraction Value ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF O 1•1 _ C.OM VEH 0 ® 1 (7 KM8J3CAL9JU773867 State Farm ❑y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 3037621-SFP-13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER Same VEHU 73 L ❑Y ®N 2 0 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES ❑RUM ❑CCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / l J 01 9 9 9 FOR DAMAGED AREA(S) mONf DUE TO�RASH NAME(LAST,FIRST,M) Bradford.Alexis,A. 0mo day El Dorado MfgE2ktder 2007 00-NONE 11-1 t r ,s 1 ❑ ® 29xi v 13-UNDER CARRIAGE 10 i ., 2 FIRE ID ® U2 C , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR n a 757 W BODE CIR 316 F SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN -OistracionValue - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 it 6 _4 COM VEH ❑ ® U1 ta C FIRST CONTACT 1 7-. .5 •&Yes,See Sidebar Hoffman Estate IL 60169 0 M172674 IL 2025 i O fn 2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)414-5079 B631-0019-9672 IL 7 1N9MNAC637C084106 Self-Insurance ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 PACE BUS Self-Insurance BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER pONI N 550 ALGONQUIN RD.60110 (847)364-7223 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAMEii)ADDRESSl/(TELEPHONE) (EMS) (HOSPITAL) 2 1 07 /22/1960 M 1 4 A 1 0 Lateef O. Giwa/520 ST CHARLES ST,ELGIN-IL-60120 Elgin Fire Sherman U2 996 (847)754 0265 m 2 4 10 /1 1 /1973 F 1 4 C 1 0 Tameka L. Veal/807 RIDGE DR 819.Dekalb-IL-60115 Elgin Fire Provena St.Joseph #OCCS D (331)422 8033 _ XI 2 5 05 /1 3/1975 M 1 4 B 1 0 Rico A. Hinton/1900 MARK AVE 2b.ELGIN,IL,60123 Elgin Fire Provena St.Joseph U1 1 m 184 718 3 3-1 3 7 5 D / / 4 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 10/17 /2024 05 47 0 pm in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 2 0 06 28 10,17 /2024 05 47 ®PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 0 AM ❑Maintenance U2 CO 11 1 ARREST NAME Cole.Jason.S. 11-709-A 1527-000225 10/17/2024 05 55 ®PM SLMT O U CITATIONS ISSUED PENDING • ROAD CLEARANCE TIME ❑Utility o N ❑ ❑ SECTION CITATION NO. AM 25 2 0 ARREST NAME 10/17 /2024 07 00 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1527-Juarez.Jorge 101 334-Fries 11 ,26/2024 01 30 0 PM Workers Am present? ®N U2 25 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. _ 0 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. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i combination).or —I INDICATE NORTH M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C L ', ', ' I O -! ` r r r (example.shuttle or charter bus)-or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier transporting - 'r 'r t transporting employees in the course of their employment(example.employee M i_. ..... _.4 4 [I transporter-usually a van type vehicle or passenger car).or al j I `_ r My„mow r i 4 Is used or designated to transport between 9 and 15 passengers including the driver, for direct compensation(example:large van used for speafic purpose) or O -- - - - - �____4 ; , i < < 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m �� MI r-- -1 I �_ C;,'.,,,y,e„o„„, placarding(example placards will be displayed on the vehicle) 71 • d I CARRIER NAME Z ' I ADDRESS• I to NO4 To sow ) I CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other ' r , ^ USDOT NO. ILCC NO. mXI , Source of above 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? O ❑ 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 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Gray Multicolor - 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE