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HomeMy WebLinkAbout2024-00068704 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 01110 IIII II IIII II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003604254 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00068704 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y 0 N 10 28 2024 ®AM ❑YES ®NO U1 LARKIN AVE Elgin11:02 g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl FT!MI N E S W N GLI FTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 -I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑Peon. ❑EouES ❑NIA/ ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) Mao TOWED U1 O • NAME{LAST,FIRST,M) mo /1 9 8 6 Ford Bronco 2024 00-NONE 11_ 12 `_1 DUE TOCRASH El ENE 13-UNDER CARRIAGE 10l !. 2 FIRE ❑ NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 2 M M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHH D 0 99-U 15-UNKNOWN THER 9 16•TOP4 `Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i� �I COM VEH 0 j$J 1 n F. FIRST CONTACT 3 7 :-----I *IIYes.See Sidebar U1 0 Z GENOA IL 60135 0 1 0 EK13678 IL 2025 ):FAR TELEPHONE IL D 7 3FMCR9B6XRRE27834 AMERICAN FAMILY INSURANCE ❑Y ®N U2 I' 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 410855708478 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ❑ N 2 eu N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O Ntry 0 NCV 0 DV !1 9 9 3 Dodge Ram 1500(pickup) 2017 oo-NONE O1 • ©Li DUETOCRASH ❑ !g 2 x o y Yr 13-UNDERCARRIAGE 10,i Ic. 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y ON ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i�..__4 COM VEH ❑ ® U1 CO 11- FIRST CONTACT 11 7 _5 •)ryes.See Sidebar C ELGIN I L 60120 0 1 0 3200158 B I L 24 I:EaR Si)0 M IL D 0 3C6RR7KT1HG709841 AMERICAN FREEDOM INSURANC ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 HERNANDEZ. EDGAR.G. 60056 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP 996 < Refused 0 Y°ND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 07 / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 10,28 l2024 11 02 ®AM❑PM in a Work Zone? ®N DIRP D co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T o" 2 0 2 99 , , 0 PM• 0 Construction 1 7 Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 a TEWKSBURY.JOHN. R. 11-901-A 1545000029 , ! PM -, ARREST NAME ❑ o u ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 30 t 2 ARREST NAME AM T El r ❑❑PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME COAM Workers present? ❑Y 30 1545-VanEycke. Brier 601 272-Bajak 11 ,26,2024 09 00 ❑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 ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1.i- �____r____; N _ combination):orra gmore thanpounds(example:truck ortruckrtrarler -I weight tin 10,000 s INDICATE NORTH i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } (example:shuttle or charter bus):or r r r X or 1:0 OI Not To Scale I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O - } } } transporting employees in the course of their employmentp (example:employee � � i. i. ..i.. ..; L - I. } transporter. sed or des gnated to translly a van type port betweeicle or n 9 and 15 enger passengers,ssen rs,including the driver, C I t�gtr( } } for direct compensation(example:plarge van used for specific purpose):or L____a..... _ t i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires III — — - � arn2 - - - placarding(example:placards will be isplayed on the vehicle). .Zm1 —1 CARRIER NAME Z If= ADDRESS 0 r---- T. CITY/STATE/ZIP 0 0 _ MOTOR CARR.ID 0 Interstate Intrastate °r"an I El 1 I r 1 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ; _Y_ __1 USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown M D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE