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HomeMy WebLinkAbout2024-00069164 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 III OH II 111111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003606399' u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 202412024-00069164 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 10 30 2024 ®AM ❑YES ®NO U1 -< N MCLEAN BLVD Elgin08:49 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 eaves 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 4 / yr 13-UNDER CARRIAGE ©1 O;!� FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O �O DISTRACTED 0 ]$I U2 0 171 F 2 5 ❑Y ❑SYSNEM IN®UNK VEH. 9 AT CRASH 9 99-UNKNOWNUTHER 016-T Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D it �I COM VEH 0 j$J 1 n F. FIRST CONTACT 12 7__:1L6_,__5 *IIYes.SeeSidebar U1 0 Z Elgin IL 60123 B 1 0 DQ38173 IL 2025 REAR TELEPHONE IL D JTDJT923375076493 STATE FARM ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 1370756SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ❑ N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NOV ❑DV !1 9 5 3 Peterbilt Motot�7go. 2005 00-NONE ,1_"j Q�,-_, DUE TO CRASH p (g► 21 0mo 13-UNDER CARRIAGE 19( I 2 FIRE ID (21 U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 g I N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 s 7i1 B 4 COM VEH El ❑ .5 •(ryes,See Sidebar U1 COC — River Grove IL 60171 0 1 0 32580V IL 2025 REAR g IL A 7 1XP5DB9X55N852987 Acuity ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same X52231 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)l(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL) U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occAur 0 Y U2 Z El N 1 CD 11 4 10,30 /2024 08 49 0 PM in a Work Zone? NJN o1RP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 0 T F.; 2 ❑ 2 25 , , 0 PM ❑Construction * N 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 -, ® 11 4 ARREST NAME Romero-Marquez. Ruth.S. 11-901-A w326000068 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 45 t 2 ARREST NAME AM T / / ❑❑PM 0 Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 326-Hornsby. Marc 502 275-Engelke / , ❑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. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< I t I dit, !. INDICATE NORTH p1 BY ARROW combination):or -I 2 Is used or designed to transport more than 15 passengers including the driver C } "Z.. - } (example:shuttle or charter bus):or 0 hbr no 5tw.c1 env I [ - 3. Is designed to carry15 or fewer passengers and operated a contract carrier O I I } } } transporting employee In the course of their employment(example:employee y a van type vehicle or L L.___a___..I. 4alsuosedordrter- esllnatedtotransportbetween9a dr15passengers,includirgthedriver, } } } g transport CCO ma 1 — VA for direct compensation(example:large van used for specific purpose):or ___-I S- + �- wawa f - i. . i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p D °bTA°i100 CARRIER NAME Henrys Express Transportation z ADDRESS 404 KERRY CT w I I CITY/STATE/ZIP Carol Stream I IL 160188 g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 I r 1 ❑ Not in Comm./Gout. 0 Not in Comm./Other - USDOT NO. ILCC NO. 145308 xi Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAEP 0 Yes ®No 2 TRAILER VIN 1 5 MAD N22217C013290 m to LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 ® 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 22f ft. 2 ft. w Black Red u 1 TOWED • TOTAL VEHICLE LENGTH 34ft ft. NO.OF AXLES 2 DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE 5 LOAD TYPE 9 Other/Unknown