HomeMy WebLinkAbout2024-00070289 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X403613528
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00070289 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 11 04 2024 ❑AM ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 02:56 ®PM FLOW CONDITION M
®10(�!MI N EON Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 n
0 8 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 8 rn
M 2 4 SYTM❑Y ®SNEDUNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S ii,4 COM VEH 0 Ea 1 0
F• Elgin IL 60124 0 1 0 FIRST CONTACT 11 7_;1 __5 *IIYes.SeeSidebar U1
Z 9 FA11218 IL 2025 REAR
TELEPHONE
IL D 0 1J8HG58N66C318801 StateFarm ❑Y ®N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Cameron. Kelli. L. 3438430-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 ,�=Q)OS •!ryes.See Sidebar C
Z SOUTH ELGIN IL 60177 0 1 0 68329EL IL 2022 i Si)0
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IL D 0 7SAYGDEE1 PF706032 StateFarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0959655-SFP-13 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)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 09 / F 2 3 0 1 0
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71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 11 ,41 ,024 02 56 ®PM 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
0 2 03 99 , , ❑PM ❑Construction >F
5
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Cameron. Everett.J. 11-601-Ax 1528-000168 , r El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
El AM
t 2 El ARREST NAME 11!4) 1024 03 40 0 PM El Unknown work zone type U1 5O
2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
1528-Rivera. Kevin 801 334-Fries 11 ,26,2024 01 30 ®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 S I a 1 b al* s I4I4 - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I I I I - 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- %-- --I-- --; I I I I 7 F INDICATE NORTH combination):or
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I I I r - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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3. Is designed to carry15 or fewer passengers and operated a contract carrier O
L I------I----; o- s - L } } } transportingemployees in the course of their employment(example:employee X
n- ____ o- transporter-usually a van type vehicle or passenger car): r 03
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L L.__.a__-_.I e • s - 1. I I 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
1 d for direct compensation(example:large van used for specific purpose):or O
4, ` L L L . L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires 'D
a v ., Pc M
y K, placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 0
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,,,,,,,,�. - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
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Y USDOT NO. ILCC NO. C
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Source of above z
. Form Number m
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Blue
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE