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HomeMy WebLinkAbout2024-00071806 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIIl IIIIII 011001111110 HU000 III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003622538 u, 1 U2 1 1 1 U116 u2 u, 1 U2 u, 1 U2 4 4 u, 1 U2 *P 0119* 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 El$501-51.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00071806 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 11 12 2024 ®AM ❑YES ®NO U1 -< ROUTE 20 HWY Elgin 05:37 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m LongcommonCOUNTY PROPERTY 0 Y Ill N DOORING Ely #OF MOTOR 0 SLOW CA ONO/MI NO s w Pk Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 4 0 FOR DAMAGEDAREA(S) FRO T TOWED U1 Q Ober kevin. 1 1 / yr 13-UNDER CARRIAGE © NI ,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 is-OTHER 99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s �--it a �i COM VEH 0 j$J 1 00 f. FIRST CONTACT 11 7_; _;__5 *lIYes.See Sidebar U1 Z Genoa IL 60135 0 1 0 CQ83674 IL 2025 REAR TELEPHONE IL D 0 1 G KKN U L4XMZ186202 State Farm ❑Y ®N U2 ni 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 1655983 sfp 13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused E]Y ❑ N 9 2 ou ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 i v 0 Dv yr ,2 - C o 13-UNDER CARRIAGE 10 I 2 FIRE 0 0 U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 - POINT OF s-.;, -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:-6 C•IO e1sVEH 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) (SEAT) (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 ❑Y U2 Z N 1 ® 15 1 State of Illinois.2016-00040901 Deer 11 ,12 /2024 05 37 ®❑PM in a work zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 0 Si t 2 0 801 E SANGAMON AVE Springfield. 90210 21 28 ! , ❑PM ❑Construction * Z3 ❑ I'i CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 - ❑Utility a, ARREST NAME Oberg.kevin.j. 11-601-Ax S1546-000022 t r ID SLMT o u1 0 o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑CITATIONS ISSUED ❑PENDING AM U, 55 r 2 El ARREST NAME 1 1 1 1 2 12024 06 21 0 PM ❑Unknown work zone type n TIME OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE 2 3 ❑ ❑AM Workers present? ❑Y 1546-Ignacio. Patricia 801 12 , 17,2024 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. CIO 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 - c ` --I -' • r INDICATE NORTH combination):or -I Not To Scale 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - i. e. (example:shuttle or charter bus):or 0 X L A � 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or o L i L i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z ADDRESS 0 C) unit.,_ _ _ MEWCITY/STATE/ZIP . i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5 I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 �"---- --1 era+nnw.72o - USDOT NO. ILCC NO. m 73 Source of above z . GVWR/GCWR m 0 <10,000 0 10,000-26,000 0 >26,000 z —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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? A ❑ Yes II Ell 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 co 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray 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_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE