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HomeMy WebLinkAbout2024-00070406 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 VII 111111 1111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *MOM 13592' u, 1 U2 1 1 2 U116 u2 U, 1 1_12 U, 1 U2 4 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00070406 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 04 2024 ❑AM ❑YES ®NO U1 -< WELD RD Elgin mo /day/yr 11.32 ®PM FLOW CONDITION m I 20 ®!MI N OE S W Second St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 3 / yr ©1 QQ - 1 OUE TO CRASH ® 0 13-UNDER CARRIAGE 10 , 2 FIRE 0 NIC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 4 El ®N SYSTEM❑UNK VEH. ATCRASHD 99-UNKNOWN 9t6•TOP 3 `Distraction Value 9 ALGN = r COM VEH 0 j$J 1 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it ii,4 00 ELGIN I N I L 60120 0 1 0 FIRST CONTACT 11 7_:, -__5 *II Yes.See Sidebar U1 Z EF55228 IL 2024 REAR TELEPHONE IL D 0 1 G2ZG57BX84157759 American Alliance ❑Y Il N U2 ni 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co 99 9 Same I LAA0986001 00 2 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 _ 71 o 13-UNDER CARRIAGE 10 I 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT YA='+:-5 COM•I f sVEH See •Sidebar❑ 0 C CO F` ---. co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 1 Illinois.State.o. Speed sign on Weld Rd. 11 ,04 ,2024 11 33 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v t 2 0 150 DEXTER CT ELGIN IL 60120 11 99 ! ! ❑PM El Construction * Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM ' o u 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 DAM F 2 ElARREST NAME 11 r 05 /2024 12 25 ®PM ElUnknown work zone type U1 35 cf T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 0 - ❑AM Workers present? ❑ 1524 Silva Jose 702 , ❑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 truckrtrailer -< ` ` -' -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or 07 - ----- -•-•; transporting employened to es Inthe course of 5 or fewer passengers e e mplanoyment(example:employee a contract ner aim } r } transporter-usually a van type vehicle or passenger car): r w :- :- --}----+ MED \... - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y I�D for direct compensation(example:large van used for specific purpose):or O L "____a____1 _ l. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI 1NId 0 91id. CARRIER NAME Z ADDRESS 0 Not To Scale ! Lthast D CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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'; 0 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE