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HomeMy WebLinkAbout2024-00071176 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110011 III Ill II HI Oil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00361D303 u, 1 U21 3 4 1 U1 3 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 1 U2 3 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00071176 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 S MCLEAN BLVD Elgin 04:32 ® ❑ RELATED ®Y 0 N 11 08 2024 ❑AM ❑YES ®NO U1 -< _ _ PRIVATE mo /day/yr ®PM FLOW CONDITION MFT l MI N E S W FLEETWOOD DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 6 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171 M 2 5 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il 6 4 COM VEH 0 Ea 1 0 ~ ELGIN I L 60123 B 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar U1 Z AP76471 IL 2024 E TELEPHONE IL 0 1 MEFM55S72A633533 American Alliance ❑Y Il N U2 1- in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same I LAA-0587869-08 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y El 2 ou m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 yr 16 j t2 , z FIRE 0 ® U2 C o 13-UNDER CARRIAGE c M 2 6SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN 0istraglon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j( 4 COM VEH ❑ ® U1 CO FIRST CONTACT 3 7 .'----.-5 •It Yes.See Sidebar = ELGIN IL 60123 0 1 0 BF50745 IL 2024 I0 IL D 0 2G 1 FB1 E31 D9142150 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 811507587 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!((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 11 / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 11 ,08 /2024 04 32 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 25 28 / / ❑PM ❑Construction >E R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 4 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Jarrette. Phillip. B. 11-306 488000210 11/08/2024 ❑PM SLMT S' N - ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑0 Am Utility r 2 El ARREST NAME 1 1/08 /2024 06 14 ®PM 0 Unknown work zone type U1 3O 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? ❑Y 30 488-Ramos.Arely 701 223-Hughes 12 , 10/2024 01 30 0 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 • • 0 . c r r , I I I ■ r 1 Has fight rating more than 10,000 pounds(example:truck or truck trailer INDICATE NORTH 1. -< ■ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or Fleetwood/Dr. I© 3. Is des ned to car 15 or fewer` A fig ry passengers and operated by a contract career O - - - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L 4. Is used or designated to transport between 9 and 15 passengers,including y--- ----; - } } } g po pafic purpose): rs,includi the driver, — — — — for direct compensation(example:large van used for specific p or L L____a____. (i=_`,;A _ t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m — placarding(example:placards will be displayed on the vehicle). ;p D �+ t I CARRIER NAME —I W� I I I '' ADDRESS D a Im (A 1 cCITY/STATE/ZIPI - MOTOR CARR.ID 0 Interstate 0 Intrastate 5 ' - - I I I USDOT NO. ❑ Not in Comm./Govt. Not in Comm./Other --- Y----1 - ILCC NO. rn XI Source of above z . • m 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? ❑ Yes II No ElUnknown 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 0 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 Red 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 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE—LOAD TYPE