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HomeMy WebLinkAbout2024-00067233 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III )III III ll II 11111111111111111011111101111111 DRAG TRFD TRFC WEAT DRVA VIS VEND ' LGHT COLL MANY XQO3596425 u, 9 U2 1 1 1 U199 U2 1 U199 U2 U1 99 U2 1 5 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE[23 NOT ON 1 VEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067233 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 51 BIRCH DR ❑Elgin RELATED ❑Y coN 10 21 2024 07:30 ®AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ❑PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y M N DOORING ❑Y #OF MOTOR 0 SLOW 1 U) ❑ FT/MI N E S W Cook HIT&RUN ®Y ❑ N WITH N VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 D4 ORNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 .0. Unknown Unknown 00-NONE it 12 i' , DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) ,r 2 FIRE 0 ISl < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 ® U2 m 9 16-TOP 3 r / ❑Y ❑N ❑UNK VEH. AT CRASH . POINT OFO 8 it 4 V 0 ®Distraction ValueValueALGN CITY PLATE NO. STATE YEAR } 6 ii COM EH1 I— FIRSTFIRST CONTACT 99 7_ :REAR 5 "If Yes,See Sidebar U1 0 °c Z p . ID VIN INSURANCE CO. EXPIRED 1 -13 unknown ❑Y 0 N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a r 99 9 Same unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU X L ❑Y ❑N Same 99 0 m ❑DRIVER ® PARKED 0 DRIVERLESS 0 PED ❑PEDAL ❑EOUES 0 NIAV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Chevrolet Malibu 2011 oo-NONE 11: 12 , '1 DUE TO CRASH 0 212 73 c 13-UNDER CARRIAGE 10 I I: p FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 IN SPDR 0 a ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value g 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 4 COM VEH 0 ® U107 FIRST CONTACT 7 0 6 • E •If Yes,See Sidebar EL58349 IL REAR g cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1G1ZC5E15BF187466 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Pizana_ Lucia 932572391 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 1121 BIRCH DR 12. ELGIN . IL.60120 (224)855-0165 U1 = {UNIT) (SEAT) {DOB) )SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)1{ADDRESS)1ITELEPHONEI {EMS) (HOSPITAL) 0 I I - U2 996 r m / / - #OCCS y / / 73 • U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 21 18 9 10/21 /2024 11 25 ❑pM in a Work Zone? El DIRP CO 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 3 0 T 2 0 18 18 ! 1 0 PM ElConstruction * c' 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 3 Q ® 11 1 ARREST NAME / / El PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 30 2 0 ARREST NAME 1 1 pti1 ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El Y 30 547 Homeier,William 272-Bajak , ElPM ElN 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. _ 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 / i ; ; combination) or —I INDICATE NORTH XI fBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ -; ! ` r r r (example.shuttle or charter bus)-or n l X ` tr Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----• - . } } } transporting employees in the course of their employment(example.employee 7, ; transporter-usually a van type vehicle or passenger car).or CO r) . : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C Not Tam for direct compensation(example:large van used for specific purpose).or O ` ~ y i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ,.� °or. _ placarding(example placards will be displayed on the vehicle) 71 _ CARRIER NAME ' _ .. ADDRESS '� is�4 U) . �qy • CITY/STATE/ZIP C) MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. m XI , Source of above Z ❑ Yes 0 No ❑ Unknown 0 Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No - MCS El 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 Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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