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HomeMy WebLinkAbout2024-00069833 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 01101100 II 0 1� DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a615100 u, 9 U29 1 1 1 U, 2 U2 1 u,99 U299 u,99 U2 99 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 13 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00069833 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 894 STEWART AVE El In 11:20 ® ❑ RELATED 0 Y ®N 11 01 2024 DAM ❑YES El NO U1 —< _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl) ❑ FT/MI N E S W Cook HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I &RUN ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) FOR DAMAGEDAREA(S) .FROM TOWED U1 0Unknown.0. / ! Ford Escape 00-NONE ©1 O , DUE TO CRASH 0 NAME(LAST,FIRST.M) mo yr 13-UNDER CARRIAGE 10. EN I , 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<11 SYSTEM IN ENGAGED 15-OTHER 9 ,6.TOP 3 9 9 ❑Y ID N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s a r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,Ii_S Ii,_ 1 1- FIRST 9 0 FIRST CONTACT 11 7_: COM VEH 0 ZgJ_5 *IIYes.See&debar U1 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) NIA ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same NIA 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 99 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr 10.j 12 c., 2 FIRE ❑ ® U2 99 C o 13-UNDER CARRIAGE c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 0 ® SPDR n ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 9 - POINT OF 8 i_l a N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II 1 jt'.,_ COM VEH 0 ® CO F,,, FIRST CONTACT 7 Q11—��_5 •IfYes,See Sidebar 3385857B IL 2025 REAR 9 cn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTEW1 EP3JKE28490 NIA ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Robert.Corcoran.T. NIA BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 2 11 ,02 l2024 01 30 ®PM in a Work Zone? ®N DIRP co 1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP H . AM U1 � 2 0 1 2 18 18 N 3 0 ❑CITATIONS ISSUED ID PENDING + ! ❑PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 —a, ARREST NAME / / ❑PM ' o N ® 11 9 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 30 F 2 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1538 Estrada. Leticia 200 404 Duffy , ! ❑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 INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r ,. (example:shuttle or charter bus):or 0 L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O - Not To ac r•J i. } } } transporting employees in the course of their employment(example:employee 73 transporter-usually a van type vehicle or passenger car):or w L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L____a____. o °o°"''D t i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m .. 1 placarding(example:placards will be displayed on the vehicle). XI II21. f CARRIER NAME Z ADDRESS 0 erwurrn» 14. n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----'Y----1 - USDOT NO. ILCC NO. rn 73 Source of above 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? ❑ Yes II No El Unknown A 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE