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HomeMy WebLinkAbout2024-00069149 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 101101100 II 0 10 H11111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003611478 u, 1 U21 3 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U, 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00069149 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 10 30 2024 ®AM ❑YES ®NO U1 -< N RANDALL RD Elgin mo /day/yr 07:34 ❑PM FLOW CONDITION M gi0 gC7!MI N E C)W Auto Mall Dr COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ❑SLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 1g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 r tf TOWED U1 0 FOR DAMAGEDAREA(S) FRO Kul lewicz. Brian. K. 0 6 / yr 13-UNDER CARRIAGE ©, :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El 0U2 5 M M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _ El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,;il S �i 4 COM VEH 0 El 1 00 F. FIRST CONTACT 1 7 -___5 *IIYes.See Sidebar U1 Z Crystal Lake IL 60014 0 1 AW56568 IL 2023 ; TELEPHONE IL D 1 G NSKCKC3H R387038 Allmerica Financial Allia ❑Y J N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 1-1 Same A1C-H933145 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ❑ N 2 0 Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDA. 0 EWES O NMv 0 NOV 0 DV /1 9 8 9 Kia Motors Col portage 2023 00-NONE 'o,1 t2 (,-2 DUE O CRASH rg ® U2 2 C o 13-UNDER CARRIAGE c F 2 4 SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 9 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .I. 4 COM VEH ❑ ® Ut W FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.See Sidebar C ELGIN Z I L 60123 0 1 AR76252 I L 2025 i 9 1J7 M IL D 5XYK6CAF8PG056395 Safeco ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same Z5294103 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused 0 Y°ND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 6 02 / / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 1 3 Kane County Clerk Unit 25 light pole 10/30 /2024 07 34 ®❑pM AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � v T 2 0 41W011 BURLINGTON RD St Charley 60175 08 28 ! / ❑AM ❑Construction >F Z 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o El 11 1 ARREST NAME Kulgiewicz. Brian. K. 11-601 1540000019 / / ❑PM SLMT lgi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N DI AM 50 t 2 0 ARREST NAME Kulgiewicz. Brian. K. 11-708 1540000020 ! / PM ❑Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 50 414-Lara. Saul 901 404-Duffy 12 / 12/2024 01 30 ElPM Workers present? ®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 CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< - }----i-- --; } } } r -, , ; ; , ; ( combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (example:shuttle or charter bus):or X 3. Is L L----A--- 1 i. '-----.i.... J transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 I- <.__-a-_-_-I , li I• I- <--_-a-___� , , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-.�____� l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI -I—I CARRIER NAME Z ADDRESS , CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . Form Number 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 Tan Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE