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HomeMy WebLinkAbout2024-00067576 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets I li Ill III 1In ll 11111111111111111111 IHI lU II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2258 u, 1 U2 1 1 1 U199 u2 U, 1 U2 Ut 1 U2 4 4 Ut 1 U2 *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 SCENED NOT ON 3 VEHICLE/PROPERTY 0 OVER$1.500 El AMENDED (DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067576 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I RT20 WB HWY Elgin ❑ RELATED El Y coN 10 22 2024 11:25 ❑AM ❑YES ®NO U1 .< PRIVATE mo /day/yr ®PM FLOW CONDITION m ®1 8 FT/® N E S® South ) PEDALCYCUST® ® FREE FLOW # LNS 0 I&DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo 0 PEDAL 0 EOUES 0 NIN 0 Ncv 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGED AREA(S) FRONT TOWED U, NAME(LAST,FIRST,M) 0 6 / 1 0 J 1 9 9 4 Volkswagen Jetta 2020 00-NONE DUE TO CRASH . Karl. L. ayyr g ®' © + ❑ 21 ,3-UNDERCARRIAGE 1 2 FIRE 0 ® E SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 1lej U2 m 1785 RUBY DR M SYTM El Y ®SNE❑UNK VEH. O AT CRASH D 0 15-99-UUNKNOWN THER9 16-TOP 3 ,Distraction Value 9 ALGN = 9- CITY PLATE NO. STATE YEAR POINT OF 8 116 I( COM VEH 0 El 1 C) F FIRST CONTACT 1 7 t_ 'If Yes,See Sidebar U1 0 Z 3VWN57BU1 LM021938 Country Financial ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 49 Same P010452785 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 G) m 0 DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EQUES 0 NUV ❑NCV 0 ON DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m / / FOR DAMAGED AREA(S) FRONT TOWED fi + DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C c 13-UNDER CARRIAGE 101 2 FIRE ❑ ❑ U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR C)Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •DistractionValue U1 0 - El POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_Il 61_S CIOMe63eeSideba❑ ❑ C F R • C 0.3 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < RESPDY DNR U, 2 (UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n / / U2 r M / / - - #OCCS ' D / / U1 1 D / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ID U2 Z 1 N 1 ® 15 1 State of Illinois Deer 10,22 ,2024 11 25 ®PM in a Work Zone? ®N DIRP co 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 150 DEXTER CT ELGIN IL 60120 21 99 ! 1 0 PM El Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM El Maintenance U2 Q ARREST NAME / / ❑PM SLMT o U 1 ❑ • 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 2 N 8 AM 45 2 ❑ ARREST NAME ( / ptil ❑Unknown work zone type Ut % T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ ❑AM Workers present? CI1541 Wilkerson.Tondeo 702 / p 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 ', ! 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------t-----• + + • : - -, 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 designated to transport between 9 and 15 passengers,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 T. . ` 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 ,-•---, - DO ILCC NO. m U N XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 73 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 E Did Carrier Safety Regulations(MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 >102 m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z En Silver - U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE