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HomeMy WebLinkAbout2024-00069155 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 III 1111011010100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003607775 u, 1 U29 3 4 1 U, 7 U216 u, 1 U299 U, 1 u2 99 1 11 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 202412024-00069155 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n ® ❑ RELATED PRIVATE ❑Y ®N 10 30 2024 ®AM ❑YES ®NO U1 N STATE ST Elgin mo /day/yr 07:50 ❑PM FLOW CONDITION m _ �O ICJ O COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn !MI N E S W Frazier Ave WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J V ❑ N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 0 3 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 4 rn M 2 SY5 ❑Y ❑SNEM❑UNK VEH. O AT CRASH O IN ENGAGED 99-UNKNOWN 9 16•TOP 3 *Detraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 COM VEH ❑ Ea 1 0 ~ ELGIN IL 60120 B 1 0 FIRST CONTACT 12 7_;1 __5 *IrVes.See Sidebar Ut Z EN69407 IL 2024 REAR TELEPHONE IL D 0 1G1ZB5STORF105257 STATE FARM ❑Y ®N U2 13 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 3398182 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 NPAy ❑NKV ❑DV yr ,a j 12 c 2 FIRE ❑ El U2 C Ti 13-UNDER CARRIAGE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER 911,6•TOP3 ❑ ® SPDR n 9 9 ❑Y El N ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 U1 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® CO F,,, FIRST CONTACT 6 O7 a=Q OS •IfYes.See Sidebar C 0 1 0 REAR 9 M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 UNKNOWN ❑Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same UNKNOWN BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < ElYRESPONDER E U1 = Y (UNIT) (SEATI (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 ❑Y U2 Z N 1 ® 11 1 10,30 /2024 07 51 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 ❑ 28 99 N 3 0 0 CITATIONS ISSUED 0 PENDING + ) ❑PM• El Construction >E SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME / / El PM 1 ® 11 1 ❑CITATIONS ISSUED PENDING UtilitySLMT N SECTION CITATION NO. ROAD CLEARANCE TIME o ❑ AM U1 35 t 2 El ARREST NAME 10 i 30 )2024 09 10 [M PM ❑Unknown work zone type - n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 1544 Solis•Yulissa 501 404 Duffy , 0 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••--, , I N.9STATE?ST - A CMV is defined as any motor vehicle used to transport passengers or property and: Z I Iratingmore than pounds(example:truck or truck trailer 1. Has a weight 10 000 i- }__-_-----_1 N } combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 C MB/I - r (example:shuttle or charter bus):or passengers including the driver 0 . A I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees in the course of their employment(example:employee X i transporter-usually a van type vehicle or passenger car):or L L.___a__ t l�� 4. Is used or designatedtotrans rtbetween9and15passengers,includingthedrrver, y �^trl I } } } for direct compenation(example:large van used for speific purose):or < . I. 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a placarding(example:placards will be displayed on the vehicle). XI _ CARRIER NAME Z ADDRESS T. ` musenave. (n CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate O I I . I - -- - - ❑ Not in Comm./Govt. Not in Comm./Other ----Y --; [ Not To Scale -I - i. ; ; ° °< ._ USDOT NO. ILCC NO. m XI Source of above Z . • m 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE