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HomeMy WebLinkAbout2024-00068919 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a606450` u, 1 U21 1 1 1 U1 5 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 6 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00068919 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 10 29 2024 NAM ❑YES N NO U1 -< W HIGHLAND AVE Elgin07:42 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FTlMI N E S W SHAGBARK DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ Kane HIT&RUN ❑Y N N WITH VEHICLESOT, INVLD DO STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Es final Diaz. Israel 0 4 / yr 13-UNDER CARRIAGE ©i " 2 FIRE 0 N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 016•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH ❑ j$J 1 0 F. ELGIN IL 60123 0 1 0 FIRST CONTACT 10 7 ; _5 *Irves.See Sidebar U1 Z AS83214 IL 2024 Ismi TELEPHONE IL D 0 W08AT671085067010 Kemper 0 Y igiJ N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12AU001105163 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y El 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 KKv 0 Dv CIRCLE NUMBER(S) U1 !1 9 8 6 Subaru XV Crosstrek 2.0 2013 00-NONE ,�__' 12 0 DUE TO CRASH ❑ ( 2 Ti 13-UNDER CARRIAGE 10 z FIRE 0 U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Ole/realm Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 ll, COM VEH 0 N U1 CO FIRST CONTACT 1 Y _, _5 •(ryes.See Sidebar n ELGINREAR C DZ IL 60123 0 1 0 Q449589 IL 2024 IL D 0 JF2GPAKC7DH200051 All State ❑Y N N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 932 740 867 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < ElYRESPONDER E Ui = Y ;UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 10,29 l2024 07 42 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 20 99 1 1 ❑PM ❑Construction * Z 3 0 N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o u ® 11 1 ARREST NAME Espinal Diaz. Israel 11-802-A 451-1562 / ! El Pm SLMT 10 N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility AM U, 35 t 2 El ARREST NAME 1 0l 29 12024 08 15 [0 PM ❑Unknown work zone type 2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 25 451-Nisivaco. Russell 602 404-Duffy 12 + 10,2024 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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A Not To Scale ADDITIONAL UNITS FORMS. r r----r----, , - . A CMV is defined as any motor vehicle used to transport passengers or property and: Z } }----i-----; \ oN37 INDICATE NORTH 1. Has a weight rating more than 10,000poud (example:truck or truck/trailercombination):or -1 P1 \ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r (example:shuttle or charter bus):or 0 r r X 5 or fewer I- <.__-a-.-.� W?Hlerland?Ave t } } } } transportinggemned tploo aeeslin the course passengers their emplondyment ment operated bmpy a contract:employeerler O employees pbyment(example: X �s�:; t transporter usuallyvanvehiclepassengercar):or L ...I. r '` - 4.Is used ordgnatedtotrans rtbetween9a and w } } g transport passengers,including the driver, \ \ ' for direct compensation(example:large van used for specific purpose):or o L___-a..... ?, t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires \ placarding(example:placards will be displayed on the vehicle). Xt Shagbark?Ln _ > \ _ CARRIER NAME Z ADDRESS D to CITY/STATE/ZIP n g MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 USDOT NO. ILCC NO. m XI Source of above z If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 g 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 co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Tan 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 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE