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HomeMy WebLinkAbout2024-00068028 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets II II I Ill OIl III 1In ll 111111111111111111 IllIHI lU II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2268 u, 1 U2 1 3 4 2 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 2 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00068028 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'TI BIG TIMBER RD ®gin El ®Y ❑N 10 25 2024 07:01 ®AM El ®NO U1 ,< PRIVATE mo /day I yr El PM FLOW CONDITION m FT/MI N E S W N MCLEAN ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑CRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n .SHIR, N. 0 3 / 1 4 /1 9 9 4 Toyota Corolla FOR DAMAGED AREA(S) FRONT TOWED Ut 2009 00-NONE QO. D, DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE ❑ 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� z DISTRACTED 0 10 U2 99 m 1041 TODD FARM DR 1 M SYTM❑Y ®SNE❑UNK VEH. O ATCRASH D 0 99-U 15-UNKNOWN 9 16-TOP 3 Distraction Value ALGN I THER 'T.' El PLATE NO. STATE YEAR POINT OF 8 i. ::FIRST CONTACT 11 7_ .; 6- 4 COM VEH 0 El1 O .5 •Y Yes,See Sidebar U1 Z 1 NXBU40E89Z099491 FIRST CHICAGO INS.CO. ❑Y ix N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Same ILS89387902 2 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L El 1' ®N 2 0 ®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 / 7 J FOR DAMAGED AREA(S) FROM TOWED NAME(LAST,FIRST,M) MORGAN. KELLIE.S. 0mo 1day 1 9 yr 9 Lexus NX 200T 2024 13-NONE Itl 12 REocRasH O ® U2 2Xi v 13-UNDER CARRIAGE o _Z c c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ❑ ® SPOR n E. 200 WRENWOOD CIR F SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 0 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO STATE YEAR POINT OF ©1 i 4 COM VEH ❑ ® U1to FIRST CONTACT 9 a_ , •If Yell,See Sidebar C E LG I N IL 60124 0 ED99487 IL 2025 REAR 0 I� D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)912-7804 M625-5177-9679 IL D 0 JTJKKCFZ5R2030362 THE HARTFORD ❑v ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 37PH833582 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElRE Y El NR Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - #OCCS y / /• U1 1 73 Ito I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z 1 N 1 ® 11 q City of Elgin metal light pole 10/25 ,2024 07 01 ❑pM in a Work Zone? ®N DIRP cof.i I PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 7 s T 2 0 150 DEXTER CT ELGIN IL 60120 2 99 / / 0 PM El Construction * N 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 z ❑AM ❑Maintenance U2 El 11 4 'ARREST NAME ZADRAN,SHIR. N. 11-902 244-1787 / / El PM SLMT o u 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o NII AM 45 2 0 ARREST NAME / I ptil ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AAA Workers present? ❑Y 45 244-Blomberg. Michael 502 272-Bajak 11 /26/2024 01 30 ®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 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' Z } A CMV is defined as any motor vehicle used to transport passengers or property and r- -r- --, , 1 r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r 1- 1 ; i i- r r , , i INDICATE NORTH combination).or —I 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 1------'-----• 1 I • : ' ' 1 1 1 i } - i• transporting employees in the course of their employment(example.employee 73 transporter-usually a van type vehicle or passenger car).or 03 . 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) 71 M CARRIER NAME Z ' t ADDRESS 0 N O CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not m Comm./Other Q C -1 1 r r r r r•---, r - DO ILCC NO. m • U N XI , Source of above z • . ❑ Yes ❑ No ❑ Unknown E Did Carrier Safety Regulations MCS)violation contribute to the crash? ID 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Blue White u 1 TOWED — - TOTAL VEHICLE LENGTH ft. NO.OF AXLES TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO- DUEArties/Owners Residence SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE