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HomeMy WebLinkAbout2024-00071558 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 11100 00 IOU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003625245 u, 1 U29 3 4 1 U199 U2 1 U, 1 U299 U,99 U2 99 5 10 u1 1 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00071558 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 KI M BALL ST Elgin 05:55 ® ❑ RELATED ®Y ❑N 11 10 2024 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT N E S W DUNDEEAVE COUNTY PROPERTY :IY EN DOORING ❑Y #OF MOTOR 0 SLOW 99 Cl) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FROM TOWED U1 Q Guambo Guznay. Manuel. F. 0 1 / yr 13-UNDER CARRIAGE ©(O! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 12;! ❑ U2 0 m M 2 SYTM 4 ❑Y ®$NE DUNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 ,Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1, COM VEH 0 E! 1 Z ELGIN IL 60120 0 1 0 ET78295 IL FIRST CONTACT 11 T_; __s Yes.See sidebar Ut 0 REAR TELEPHONE IL D 1 FAHP3F24CL280247 No Insurance ❑Y 0 N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same NIA 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 ou g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 l uv 0 Ncv 0 Dv yr 10 j t2 c•, 2 FIRE ❑ ® U2 C o 13-UNDER CARRIAGE c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9:1,6•TtOP 3 0 ® SPDR n 9 9 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value U1 4 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 99 7 ='L.=5 •CIf°MSYSee Sidebar EH ❑ ® CO 0 9 REAR 4 Sn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 NIA ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same NIA 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),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 El 11 1 11 ,10 /2024 06 04 0 AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 28 19 11,10 /2024 06 07 mi PM ❑Construction 8 R 3 ❑ ]$I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Guambo Guznay. Manuel. F. 6-101 752432 11/10/2024 06 10 ®PM SLMT 1 ® 11 9 El CITATIONS ISSUED 0 PENDING Utility o uSECTION CITATION NO. ROAD CLEARANCE TIME • AM• 0 T 2 ❑ ARREST NAME Guambo Guznay. Manuel. F. 3-707 752433 11/10 /2024 06 30 ®PM ❑Unknown work zone type U1to 35 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1525-NavE.Oscar 301 12 , 11 ,2024 09 00 ❑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 r 114 // /y combination):or more than pounds(example:truck or truckrtrarler 1. Has a weight rating10 000 i -< INDICATE NORTH Not To Scale I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i , - } ,. ,. (example:shuttle or charter bus):or /'"^'" / 3. is des ned to car 15 or fewer ssen ers and o rated a contract career O l- <.__-A-.-.� ® "'' / } } } } transporting employees in the course of their employment(example:employee X < <.___a.._.� - 1 1 I �sedordrter- �llnatedtotrans vehicle rtbetween9andr15r) ssen rs,including[hedriver, C } } for direct compensation(examp large van used for specific purpose):or 0 L i 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). XI Z CARRIER NAME Z ADDRESS 0n/7/ CITY/STATE/ZIPg MOTOR CARR.ID ❑ Interstate ❑ IntrastateIi l / ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ' "-——1 i i- USDOT NO. ILCC NO. m 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? 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 VIN 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 White 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 DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE