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HomeMy WebLinkAbout2024-00066621 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111111111011101111011011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035°3590" u, 1 U29 1 1 9 U199 u2 1 U, 1 U299 1.11 99 U2 1 9 9 Ut 1 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 SCENE • 7 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066621 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 ALFT LN ® ❑ Elgin RELATED ❑Y co" 10 18 2024 02:44 ❑AM ❑YES ®No u1 ,-‹ PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ®Y ❑" DOORING ❑y #OF MOTOR ❑SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD 0 STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 oRNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 Unknown Unknown DO-NONE it 12 i' , DUE TO CRASH 021 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 ,r 2 FIRE 0 ISI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 ® U2 0 m ion .1— ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN 8 it ii 4 COM VI EH�� 0 ® ALGN OF CITY PLATE NO. STATE YEAR } 6 1 m F ID VIN INSURANCE CO. EXPIRED 1 _ I— ° NIA ❑Y 0 N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Ya r Same NIA 9 I— t. HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER S VEHU L ❑Y ® Same" 99 0 ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NIA, ❑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 Toyota Corolla 2004 00-NONE 1 y DUE TO CRASH ❑ ® 2 c 13-UNDER CARRIAGE O:j 12 _2 FIRE ❑ MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPEAR n a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH 0 ® to C FIRST CONTACT 11 7__.1 __5 •IC;Yee,See Sidebar 6062262 I L 2025 REAR 9 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T1 BE30K54U877204 Allstate 0 y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Tereza. Michael.J. 912366291 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElES Y ElPON RESPONDER 9 15 OAK ST. Port Barrington. IL.60010 (847)833-1199 U1 = {UNIT) (SEAT) {DOB) ISEXI (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)1{ADDRESS)i(TELEPHONE) {EMS) (HOSPITAL) n I I U2 996 1— m / / - '#OCCS > / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 18 5 10/18 /2024 02 44 ®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 ! 1 0 PM El Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q ® 11 5 ARREST NAME / / El PM 0 Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8AM 10 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1 529-Audi red.Jonathan 901 334-Fries / 0 PM Workers present? ®N U2 10 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 x combination) or —I INDICATE NORTH XI BYARROW 2 Is used or designed to transport more than 15 passengers including the driver C i 1 ', i ! ` r r r (3e.xample.shuttle or charter bus)-or 0X Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----;-----% i -i i- } i- transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_- -`- --' r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O L_____:_____; i ; 1 i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m MO grew, placarding(example placards will be displayed on the vehicle) XI I. CARRIER NAME Z ADDRESS 0 N • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate ❑ Intrastate : 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown 0 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 D m 73 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D 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 't Z En Gray - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE