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HomeMy WebLinkAbout2024-00068563 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III HI IIII lull 111111111111111 11101111111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2345 u, 9 uz 1 1 1 1 U1 1 U2 1 U199 U2 1 U1 99 U2 1 4 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE • 7 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00068563 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH gg 'r1 SYMPHONY WAY ® ❑ Elgin RELATED ❑Y co" 10 27 2024 02:00 ®AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY XI Y ❑N DOORING ❑Y #OF MOTOR ID SLOW 1 U) ElFT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS O tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDDES 0 NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 . Unknown.0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH 0 ® - E NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10) 2 FIRE 0 ICI < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m SYI UNKNOWN UNKNOWN ❑Y ❑SNE®UNK VEH.M IN 9 AT CRASH ENGAGED 9 ®-UUNKNOWN 6 THER 9 16 TOP 43 •Distraction Value ALGN - r CITY PLATE NO. STATE YEAR POINT OF {I 6 ii_ COM VEH 0 El 1 0 a ~ UNKNOWN Unknown ❑Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑" 99 0 0 DRIVER ® PARKED 0 DRNERLESS ❑ PED 0 PEDAL 0 EOUES 0 NIA, ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N BMW X3 2011 oo-NONE 1t' '_1 DUE TO CRASH ❑ 21 1 NAME(LAST,FIRST,M) mo day yr ©! Z1 a 13-UNDER CARRIAGE 10 (! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH ❑ ® C H FIRST CONTACT 12 7__.1 a_5 •byes,See Sidebar BM33739 IL 2025 REAR 0 fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 SUXWX5C58BL700035 Progressive 0 Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Barradas. Maricela 976303266 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER yo0 NR 81 EAST ST.Crystal Lake. IL.60014 (815)451-0456 Ut = (UNIT) (SEAT) (DOB) (SEX) (SART) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)r!ADDRESS)1(TELEPHONEI (EIdSI (HOSPITAL) n I I - U2 996 r m / / - '#OCCS > / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N 1 ® 18 9 10/27 /2024 02 50 0 pp,1 in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 5 0 T 2 ❑ 18 18 ! / 0 PM El Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 3 Q 1 ® 11 5 ARREST NAME / / 0 PM ❑Utility SLMT 0 U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 10 2 0 ARREST NAME r / pp1 ❑Unknown work zone type U1 7 OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 537-Sanders. Richard 101 - i / ❑❑PM Workers present? ®N U2 10 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. _ 0F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS _Mot To Scale ; N _, A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer r ' INDICATE NORTH combination) or 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 i_. ..... _. 4 i } - i transporting employees in the course of their employment(example.employee XI transporter-usually a van type vehicle or passenger car).or w 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 T. CARRIER NAME Z ' t ADDRESS 0 N `wrwrwr • O • CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. XI , Source of above Z . 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 D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash% fl ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 rn 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Whiteip - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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