HomeMy WebLinkAbout2024-00069813 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a610908
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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 El5501-S1,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED IDB Injury and/or Tow Due To Crash YR 202412024-00069813 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 11 02 2024 ®AM ❑YES ®NO U1 —<
PRESTON AVE Elgin10:31
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROM TOWED U1 0
Del ado Monsalve.Ser io.A. 0 5 /
yr . Q
13-UNDER CARRIAGE �0 i 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M I 2 SYTHER
4 ❑Y IN EDUNK VEH. 0 AT CRASH M IN ENGAGED 0 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_i� 6 �i COM VEH 0 j$J 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7 : __5 *Ilves.SeeSidebar U1
Z EE68708 IL 2025
TELEPHONE
IL D 0 2HNYD2H44BH513755 First Chicago Insurance ❑Y ®N U2 m
1E EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same ILS977778-01 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused ❑Y ElN 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 KCV ❑Dv
!1 Yr 9 6 7 Buick Enclave 2011 00-NONE OI FRt2 c 2 FIREOCRASH D ® U2 2 C
I' _ ®13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:, COM VEH ❑ ® U1 W
FIRST CONTACT 11 7� _5 •If Yes.See Sidebar
I- ELGIN IL 60120 0 1 0 CJ79624 IL 2025 REAR g
IL D 0 SGAKRCED6BJ255536 Kemper ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 12AU000896452 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 El 11 1 11 r 02 /2024 10 31 ®❑PM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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1 2 ❑ 2 99 r r ❑PM El Construction *
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2 ARREST NAME AM
r r ❑❑PM ❑Unknown work zone type U1
n T El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1543-Sturgeon. Kyle 201 272—Bajak 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.
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 truck trailer -<
i- }---_r----; '4. - combination):or —I
INDICATE NORTH p1
X BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
$ I N
_ (example:shuttle or charter bus):or 0
0
I- I- --I--•--; - transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener 73
Jefferson?Ave { . I QON' I� transporter-usually a van type vehicle or passenger car):or w
} } }
L -----}----; mom r _ - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
MI for direct compensation(example:large van used for specificpurpose):
ose):or
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L i.____a____.I — — — — — — I. i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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pWcartling(example:placards will be displayed on the vehicle). ,Zt
- CARRIER NAME Z-1
ADDRESS 'n
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rn
CITY/STATE/ZIP
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Not To Scale MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --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. 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 I 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
71
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
Black Black
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