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HomeMy WebLinkAbout2024-00067053 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 1111111111111111101111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35..3:46 u, 1 U2 1 1 1 1 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 5 9 U123 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 ID ON SCENE 1 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067053 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 HARRISON ST ❑ Elgin RELATED ❑Y co" 10 18 2024 11'45 ®AM ® ❑YES NO u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 10 C/) ❑ FT/MI N E S W 'WITH VEHICLES INVLD El STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg ORNER ❑ PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL ❑EOUES 0)WV ❑Ncv ❑on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 6 / 0 4 /1 9 9 8 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 . Diana Chevrolet Tahoe 2008 00-NONE „ 12 , DUE TO CRASH p 21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1• 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 677 OAKLAND AVE F ❑Y ESYlM El UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 l-1 6 ii 4 COM VEH 0 El 1 O 1 G N FK13038R224772 Kemper ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same 12AU001350782 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU L ❑Y ®" 1 G1 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m r. / / FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) mo day yr Harley ❑avidsbtL883 2019 oo-NONE 1t. 1$r , DUE TOCRASH 0 ® 1 c 13-UNDER CARRIAGE 10 1 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED0 A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3O 0 El SPDR X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN 8 O•Distraction Value U1 0 - HCITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F RST COONTACT F 5 7_ 6 • OS Clfve6VSeeSidebar❑ ® C ET9756 IL 2024 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 HD4LE21XKC421526 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Dwyer. Donna,J. G425290D1713 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y 9NR 121 2ND AVE. BARTLETT. IL.60103 (847)346-2109 U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)IITELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 r m / / - #OCCS y / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N 1 ® 18 1 10,20 ,2024 01 10 0 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 3 0 T 2 ❑ 30 15 ! / 0 PM ❑Construction * 1 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 3 Q ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 ❑ ARREST NAME , / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST • SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present?. El 25 558-Lara. -izette 401 272-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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I 0 ADDITIONAL UNITS FORMS . ' } 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 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 ', ! (- ._ ' ' '. ', ' 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------.-----• + + • : - -, 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 Z ' .. ADDRESS 0 N • CITY/STATE/ZIP 0 , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, - DO ILCC NO. m U N XI , Source of above z . MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m X1 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 >10; m m TRAILER 1 ❑ ❑ ❑ z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't N Black Black - 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