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HomeMy WebLinkAbout2024-00066546 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIII lull 111111111111 1111101 1111 111111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35..35&2- u, 1 U2 1 3 4 1 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 1 18 U123 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066546 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 '11 N MCLEAN BLVD El ❑ Elgin RELATED ®Y ❑N 10 18 2024 08:08 ®AM ❑YES ®NO U1 .( PRIVATE mo /day I yr ❑PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y ®N DOORING 0 y #OF MOTOR ®SLOW 1 U) 02 ®I MI N E C1 W Holmes Rd 'WITH VEHICLES INVLD ❑ STOPPED U2 —I AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N [] FREE FLOW # LNS O tg DRNER 0 PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EOUES 0 ARV ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 NAME(LAST,FIRST,M) mo / 5 J 1 9 8 8 Freightliner Cdt106 2010 ®-NONE 11 is , DUE TO CRASH ❑ 21 - E 13-UNDER CARRIAGE i0 1 2 FIRE 0 ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 3921 GROVE AVE 2 M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii-4 COM VEH ® ❑ 1 0 1FVHCYBS7ADAU1881 Erie Ins ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 99 9 VIP Courier Services Q111030570 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER y°®EN 2913 ELDER LN . Franklin Park. IL.60131 (773)615-3327 VEHU 0 ®COWER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 21 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N s Koulis. Pete.G. 0 8 1 7 1 9 7 2 Mercedes-Ber12LC 300 2018 00-NONE tt` �'_t DUE TO CRASH ❑ ® 2 Xi NAME(LAST,FIRST,M) mo day yr ©, v t3-UNDER CARRIAGE 10 II FIRE ❑ MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR n SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 X a` 10766 NANTUCKET LN M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7_'1 a 1_5 C•IOMe6VSee Sidebar ® U1 to PEAR C H Huntley IL 60142 0 KOULIS IL 2024 0 C .11 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)894-4647 K420-6677-2234 IL D 0 WDCOG6EB2JF413779 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 1058610SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y El NR Same Ut = (UNIT) (SEAT) (DOBi ISEX) ISAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - #OCCS y / /• U1 1 m Ito I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z N ® 11 1 10,18 /2024 08 09 ❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM If YES check one below: U1 5 T 2 ❑ 30 99 ! / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q 21 11 1• ARREST NAME Ortiz- Miguel 11-1402 W495000419 / / El PM SLMT o U ❑CITATIONS ISSUED El PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N IIAM 35 2 ❑ ARREST NAME r / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 495-Sjodir.Jacob 501 - I / ❑❑PM Workers present? ®N U2 35 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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . r-"--r---"1 , 4 . r r r r l l I 1 . r } 0 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 Z ' r • ; i ; i- r r ' i i r r INDICATE NORTH combination) or 'I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ._ I ', ! i ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 1 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 CARRIER NAME VIP Courier Serives Inc Z .. ADDRESS 2913 ELDER LN • CITY/STATE/ZIP Franklin Park I I L 160131 o . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q r•---- , USDO r r r r r•--• - 1992470 ILCC NO. 152705 m T NO xi , 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 0 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 2 Z 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 >102 m m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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