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HomeMy WebLinkAbout2024-00064016 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIII lull 11111111111111111111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036o24Or u, 1 Uz 1 1 1 1 U11 O U2 1 U, 1 U2 1 Ut 1 U2 1 1 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 1=1 NOT ON VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2024-00064016 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 71 BELLAMERE LN ❑Elgin RELATED ❑Y co" 10 07 2024 01.38 ❑AM ❑YES ®NO U1 .•< PRIVATE mo /day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 N ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 6 / 1 2 /1 9 9 4 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) ,T. y Other Other NONE 11 , DUE TO CRASH ❑ 21 mo da yr 13-UNDER CARRIAGE 10) tY 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 303 E MAIN ST M SYTM❑Y ®S NE❑UNK VEH. O AT CRASH 0D 99-U 15-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = THER i CITY PLATE NO. STATE YEAR POINT OF 8 11 6 i 4 COM VEH 0 El 1 0 m FIRST CONTACT 00 7_: __.L_5 •If Yes,See Sidebar U1 Z Acuity Ins Co ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a West Builders SP9115/X13948 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER y°DEN 303 W MAIN ST.ST CHARLES. I L.60175 (630)774-9033 VEHU 0 m 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL 0 EQUES 0 NIA, ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 14 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Chevrolet Equinox 2019 00-NONE ,t` 12 '_t DUE TO CRASH ❑ ® 2 —I c 13-UNDER CARRIAGE 10 j I. 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER O9 16-TOP 3 0 IN SPDR X ❑Y ❑ N CO UNK VEH. AT CRASH 99-UNKNOWN ©, •4 •Distraction Value 9 Ut 0 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1II 1� COM VEH ❑ ® C FIRST CONTACT 8 7__.1 a ._5 •If Yes,See Sidebar SAA626 IL 2025 REAR O fn, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 3GNAXKEV4KS634673 Cincinnati Ins Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I OConnell, Michael, P. QA10587632 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ID N 3674 BELLAMERE LN - ELGIN , IL.60124 (847)401-7508 Ut = (UNIT) (SEAT) (DOB( (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)r(ADDRESS)r(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 1— m / / - #OCCS D / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z N ® 18 1 10 r 07 /2024 01 38 ®PM in a Work Zone? ❑N DIRP D I 1 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 15 ! / 0 PM in Construction * N t 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance U2 7 Q CO 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 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? ®Y 25 483-Lynch, Miriam 900 404-Duffy / / 0 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. 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. Z : l : l : 01 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 ', ! (- t- L ' ' '. ', ' I. ` 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------i-----• + + • : - -, 1 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` 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 ,-•---, i r - DO ILCC NO. m U N XI , Source of above 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 Yellow WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 4 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