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HomeMy WebLinkAbout2024-00066775 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III (IIIIII II 1111111111111111101111111111110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593596 u, 1 U2 1 3 4 1 U199 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066775 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT S MCLEAN BLVD ❑ Elgin RELATED ®Y ❑N 10 19 2024 10_37 ®AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W MAIN LN 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR 0 SLOW 1 U) El COOK HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —1 ® AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGED AREA(S) FRONT TOWED U1 Ford Fusion 2016 00-NONE DUETOCRASH fzi NAME(LAST,FIRST,M) , Robert. L. mo 10 / day ll J yr 11- Q O ❑ 13-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 El U2 4 m 853 SCOTTS ARMY TRL M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = PLATE NO. STATE YEAR POINT OF . 6 COM VEH 0 ® 1 0 3FA6P0H75GR318784 Progressive ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same 984935624 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑N 2 G) 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FROM TOWED Y N , NAME(LAST,FIRST,M) Maya, Kimberly mo 0 8 Oa 2 yr 0 0 2 Nissan Sentra 2023 DO-NONE ;o) 12 s REo CRASH ❑❑ ® U2 2 C I', 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 a` 1718 MAPLE LN F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •DistracoonValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �6 I 4 COM VEH 0 ® U1to F, FIRST CONTACT 7 t i-� 9 -5 •If Yes,See Sidebar ELGIN IL 60123 0 DQ11591 IL 2025 I 0 S.n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)875-5037 M000-5000-2819 IL D 3N1AB8CV5PY231466 American Alliance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same ilaa095724500 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < REEl Y 0NR Same U1 = (UNIT) (SEAT) (DOB) ISEXI (SEPT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m / - '#OCCS > / / U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 11 4 10,19 /2024 10 37 ❑pM in a Work Zone? ®N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 5 C) T 2 0 28 18 ! / 0 PM El Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 5 Q CO 11 4 ARREST NAME / / ❑PM ❑Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 'd N El 35 2 0 ARREST NAME I I ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 0 AM Workers present? ❑Y 35 1545-VanEycke. Brier 602 272-Bajak I / ❑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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS 4 } 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 truckrtrailer -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 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 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No PJ 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 0 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 White Maroon - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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