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HomeMy WebLinkAbout2024-00068948 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 101101100 III liii 1100100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003606443 u, 9 U2 1 1 9 u, 2 U2 1 U199 1_12 U,99 U2 1 9 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1,500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00068948 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 ® ❑ RELATED PRIVATE ❑Y ®N 10 29 2024 ®AM ❑YES El NO U1 -< S STANDISH ST Elgin mo /day/yr 09:54 ❑PM FLOW CONDITION m 00 ® © COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR IR SLOW 1 (n !MI N E s State St WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN IZ V ElN PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN = s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 00 I- 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ UNK ❑Y ❑N U2 I- .9 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same UNK 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r D Y°N0 N -5 p DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NOV 0 DV yr Audi TT 2011 00-NONE „ 12 "_, DUE TO CRASH 0 2 73 o 13-UNDER CARRIAGE FIRE ID El U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 016-TOP 3 0 ® SPDR ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraci on Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O _ I4 COM VEH ❑ ® Ut W F„ FIRST CONTACT 99 01 i .s •If Yes.See Sidebar C CZ36370 IL 2024 REAR0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 TRUBFAFK2B1011493 State Farm ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Vargas Colin.Cesar. R. 1419678SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP U1 = {UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OW) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 9 10,29 ,2024 09 55 ®❑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 2 ❑ 18 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING • + _ 0 PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 z -a, ARREST NAME / / ❑PM ' o N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 20 r 2 ❑ ARREST NAME AM T r r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 20 499-Dirck.Cameron 701 275-Engelke r r ❑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. A. A CMV is defined as any motor vehicle used to transport passengers or property and: Z . 0 r -- ,r••--, I 1. Has a weight rating more than 10,000 pounds{example:truck or truck trailer -< } -----; I Not To Scale f - combination):or INDICATE NORTH -1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I r . ,. (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier O - I. } } transporting employee in the course of their employment� (example:employee � � transporter-usually a van type vehicle or passenger car):or CO L }-----}••••; - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C Stendteh?St I for direct compensation(example:large van used fors specific purose):or O L t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m h i _Untt� — placarding(example:placards will be displayed on the vehicle). :0 21. —I CARRIER NAME Z ' ADDRESS D 0 n CITY/STATE/ZIPg I - i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above Z . Were HAZMAT placards on vehicle? 0 Yes 0 No = 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White 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: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE