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HomeMy WebLinkAbout2024-00070984 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 01101100 01101100100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00362823 u, 9 U21 1 1 1 U199 U2 1 U,99 1_12 1 U,99 U2 1 5 12 u, 2 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00070984 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 '1 HOPPS RD Elgin ® ❑ RELATED ❑Y ®N 11 07 2024 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 06:53 ®PM FLOW CONDITION m con Or MI N E S © South Randall Rd COUNTY PROPERTY El ® N DOORING ICI #OF MOTOR 0 SLOW 15 Cn Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Unknown.0. 1 yr 13-UNDER CARRIAGE 1 ! FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OO. 2 U2 2 < 9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 DISTRACTED 0 ]$I = ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6.;i�6 4 COM VEH 0 El 1 0 I— 0 9 0 FIRST CONTACT 10 7 ; _5 *IIYes.See Sidebar U1 Z DN31355 IL 2024 REAR TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/ 3CZRZ2H71 PM701562 unlk ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m 99 9 LIETZ LSE. RONALD unk 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r RESPONDER m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 Dv 9 8 3 Mercedes-Berttltility 2024 00-NONE ,._' t2 DUETO CRASH ❑ 2 73 o 13-UNDERCARRIAGE I FIRE ❑ ® U2 M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI 6 ii, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar n ELGINREAR C D IL 60123 0 1 0 DM24-SS IL 2025 IL D 7 4JGFF8KE7RB147784 National General ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 SPECTRUM EXPRESS INC 2019176284 BAC $ 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) U2 996 m ##occs y 71 / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 2 11 ,07 /2024 06 53 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) Si 2 0 04 13 N 3 0 0 CITATIONS ISSUED 0 PENDING + ) 0 PM- El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 -a, ARREST NAME ! 1 ID PM ' oN ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT r 2 ❑ 45 AM x- T ❑PM 0 Unknown work zone type U1 ARREST NAME 1 1 ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 488-Ramos.Arely 801 334-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 unitshave 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 -< i•"''+ ' j S.4Rendefi4Rd. - 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 X - ------I----; 1 $ transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employee transporter} } } CO < ...l. • I o 1 1 sedord�llnatedtotransy a van type ehrtbetweeicle or n9andr15r) ssen rs,includingthedrrver, } } } for direct compensation(example:large van used for specific purpose):or ____a____. L i. ii. _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI " D Ell mi..,' m - CARRIER NAME Z ADDRESS 0 I CITY/STATE/ZIP g / _ MOTOR CARR.ID El Interstate El Intrastate I . ❑ Not in Comm./Govt. Not in Comm./Other -----Y- � USDOT NO. ILCC NO. C 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE