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HomeMy WebLinkAbout2024-00067278 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III (III IIIIIII II 111111111111111110111111 1111 111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E436 u, 1 U2 1 1 1 1 U116 U2 1 U, 1 U2 1 Ut 1 U2 1 1 12 U1 14 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$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 $ 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067278 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'T'I W RT20 WB ®gin ❑ RELATED ❑Y coN 10 21 2024 0310 ❑AM ❑YES ®No u1 .< PRIVATE mo /day/yr ®PM FLOW CONDITION m ®25113/MI N E s® West Grace ) PEDALCYCUST® [] FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nuv ❑rrcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 .Youel, K. 0 3 / 1 0 J 1 9 6 6 Ford F150 2012 00-NONE ®i 12 , DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 2 FIRE ❑ 10 I IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 1 m 675 DOVER DR M ❑Y ®SYSNEM DUNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 1I6-TOP 3 Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6• !1 6 ii 4 •COM VEH 0 El 1 0 r' ~ 1 FTVX1 CF9CKD45964 State Farm ❑v ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 194 8256 754 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 3 / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Zieba.Albert 0 mo day 1 9 yr9 6 Toyota Tacoma 2023 Do-NONE ;o 112 s REocRasH ❑❑ ® Uz 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPUR n SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X a 283 PICKETT CT M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ij 6 4 COM VEH ❑ ® U1 to C FIRST CONTACT 5 7. . _OS •Yves,See Sidebar BARTLETT IL 60103 0 3680934B IL 2024 •Rr 0 C TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)893-8883 Z100-0209-6084 IL D 0 3TMDZ5BN7PM159845 Erie insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same Q04 1617968 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER NEl Same Ut 2 (UNITE (SEAT) (DOBi ISEXI (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EIdSI (HOSPITAL) I I U2 996 1- m / - #OCCS ' D / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ®Y U2 Z N ® 11 1 co 10/21 /2024 03 20 0 pm in a Work Zone? ❑N DIRP D 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 El 28 03 ! / 0 PM ®Construction * N T 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 Q U2 ARREST NAME Youkanna,Youel, K. 11-601 51537-000013 / / ❑❑AM ❑Maintenance SLMT 1 CO 11 1 TIME ❑Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE o N ❑ ❑ SECTION CITATION NO. AM 55 2 0 ARREST NAME 10/21 /2024 03 10 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ®AM Workers present? El 55 1537-Mapp,Teddron 401 - 11 / 12/2024 09 00 ❑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 ', ! ' ' 1 ', ' l' ` 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 . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . 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? O ❑ 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 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 T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver Gray • - 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