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HomeMy WebLinkAbout2024-00071735 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III 11 Ii11lI DIII 00110001111 nnili111111I II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO036209S3 u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U,99 U2 99 5 10 U1 4 U2 1 *P0119* 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 ❑$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00071735 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 DUNDEE AVE Elgin 06:16 0 ❑ RELATED ®Y ❑N 11 11 2024 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W SYMPHONY WAY COUNTY PROPERTY ❑Y ® N DOORING ICIV #OF MOTOR 0 SLOW 2 fA ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FRO T TOWED U1 Q Mascote. Enri ue 1 1 / yr 13-UNDER CARRIAGE ©,I '.-2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 0 m M I 2 SY 15-OTHER 4 ❑Y ON E❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH 0 j$J 1 0 w ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_:— __5 *II yes.See Sidebar U1 Z ED87841 IL 2025 E TELEPHONE IL D 0 1 HGCV1 F3XKA131456 State Farm ❑Y Il N U2 Si . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 1947070SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 0 m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 Mks 0 Inw 0 NCv 0 DV 1 9 6 8 Toyota Tacoma 2007 00-NONE i1_"j t2--_, DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE 10'I 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction value 9 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s- 1. 6 I, 4 COM VEH 0 ® U1 W FIRST CONTACT 3 7�'_,SOS •byes,See Sidebar ELGIN IL 60123 0 1 0 1965489B IL 2025 I 4 N IL D 0 5TETX22N07Z331569 Allstate ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 811105291 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 11 /11 /2024 06 27 ®AM in a Work Zone? ®N DIRP co 1 F PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 4 n T v 2 ❑ 2 28 1 / ❑PM ❑Construction X Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 —a, ARREST NAME / / ID PM ' o u1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT AM F 2 ❑ ARREST NAME 1 1/11 /2024 ❑❑PM ❑Unknown work zone type U1 35 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 35 1525-NavE.Oscar 101 334-Fries / / ❑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 -< ` -- -. Not To,S41�/9 / / 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 / 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O < }.___A.._.� T / transportingemployees in the course of their employment(example:employee / / transportr-usually a van type vehicle or passenger car): r L ----_a----- / / - } 4. Is used or designated to transport between 9 and 15 passengers,including the driver.} } for direct compensation(examp large van used for specific purpose):or 0 L L____a..... i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires `,/ / placarding(example:placards will be displayed on the vehicle). XI D / / CARRIER NAME —I Z / / ADDRESS 0 w / / CITY/STATE/ZIP 0 g / / _ i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate . - 0I I T I / 0 Not in Comm./Govt. ❑ Not in Comm./Other ; _Y_ _-1 USDOT NO. ILCC NO. m XI 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? A ❑ Yes II El Unknown C 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 VIM 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Red 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE