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HomeMy WebLinkAbout2024-00067684 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I III lull 1111111111111111 IIIIIIIIIIIIIIIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003599344 u, 1 U21 1 1 1 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 1 18 U1 23 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 7 0 NOT ON SVEHICLE/PROPERTY El OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067684 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT S STATE ST ❑Elgin RELATED ❑Y coN 10 23 2024 01.20 ❑AM ❑YES ®NO U1 • ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ICI Y ❑N DOORING ❑Y - #OF MOTOR ®SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IZ N PEDALCYCUST®N [] FREE FLOW # LNS ' 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑ wv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 01 0 FOR DAMAGEDAREA(S) FROM TOWED U1 Bedo a.Velmar 0 6 / da J 1 9 y 1 Hummer H3 2007 00-NONE „ 12 , DUE TO CRASH p 21 NAME(LAST,FIRST,M) Y 13-UNDER CARRIAGE �p I ,. 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 EI U2 1 m 2051 ESSEX CT M ❑Y ESYlM❑UNK VEH. O AT CRASH D O 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 ii 6 -4 COMVEH 0 IZI 1 C) FIRST CONTACT 6 7 t 5 'Irves,See Sidebar U1 0 Z SGTDN13E278223340 Insurance Now Company ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 12RA000027412 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU X L • ❑Y ®N 2 G0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED s Hale.Wladyslawa. K. 1 1 0 3 1 9 3 6 Honda Accord 2001 00-NONE O' j'D1 DUE TO CRASH ❑ ® 2 XI NAME(LAST,FIRST,MI y mo day yr Q, ✓ 13-UNDER CARRIAGE 10 Ij 2 FIRE ❑ ICI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) E 1830 ETON DR F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST NT OONTACT 12 7_'1 a �_5 C•IOMe6VSee SidebaEH r ® U1 HOFFMAN ESTATES IL 60192 0 2367981 IL 2025 REAf R 0 CC11 D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)238-3968 H400-8913-6913 IL D 0 1HGCG16531A050020 State Farm Egi Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 0387432-SFP-13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same Ut 2 (UNIT) I SEAT) (DOB) ISEXI (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 09 /20/1960 M 2 4 0 1 n Mark E. Vrabel/595 S STATE ST.ELGIN.IL.60123 Refused 996 ,- (847)697-9090 , U2 m / / #OCCS D / / ut1 m / / 2 0 EV MOST EVNT co LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z N 23 1 1 5 10,23 /2024 01 29 ®pm in a Work Zone? ®N DIRP D 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 C) T 2 0 30 99 ! 1 0 PM El Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q ® 11 5 ARREST NAME / / ❑PM ❑Utility SLMT O U ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM OO T 2 0 ARREST NAME 1 / ppt ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 El AM Workers present? El Y 00 1540 Allahi. Muhammad 701 272-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. 0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } 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 I 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 I d i -` ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t------;-----% 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_____A____: : i , : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____--____; i . -: i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' ADDRESS 0 N CITY/STATE/ZIP 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 . —I Were HAZMAT placards on vehicle'? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr 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 A 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 X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ 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 Gold - 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE