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HomeMy WebLinkAbout2024-00072575 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III HH II11I1 1OUI 01100 HI DII 1111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XOOa628908 u, 9 u210 1 1 1 U110 U2 1 U199 U213 U, 1 U2 1 5 9 u, 2 u221 *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 El OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00072575 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 633 MCCLURE AVE EIIn06:57 ® ❑ RELATED ❑Y ®N 11 15 2024 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER O PARKED O DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 / ! FOR DAMAGEDAREA(S) PONT TOWED U1 Q mo NAME(LAST,FIRST.M) Unknown.0. Jeep(after 1986>}erty 2010 00-NONE 13-UNDER CARRIAGE 11 • 12 DUE TO CRASH 0 yr ) !' FIRE 0 NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O 9 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 916-TOP�3 DISTRACTED 0 0 U2 0 ❑Y (Z)N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 ii,4 COM VEH ❑ j$J 1 0 Z 0 9 0 REAR FA51251 IL FIRST CONTACT 1 7_; __6 ves.See Sidebar U1 TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED I 11/ 1J4PN2GKXAW120609 unk ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same unk 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused 0 Y ® N 2 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NOV 0 DV yr Ford Focus 2010' 00-NONE 11 '1z _1 DUE TO CRASH ❑ ® 1 a7 o 13-UNDER CARRIAGE FIRE 0 El U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR n ❑Y NJN 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value U1 0 POINT OF 6 ) -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 i'_ COM VEH ❑ ® CO F,,, FIRST CONTACT 9 7 _, _6 •(ryes.See Sidebar EV74684 IL REAR 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FAHP3EN4AW291059 USAA Casualty ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Hagerott.Anna. N. 010132834C7102 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) W 04 / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 11 /15 l2024 06 57 ®PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP H . AM U1 � 2 0 04 28 N 1 3 0 CITATIONS ISSUED 0 PENDING + ! _ ❑PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5 —a, ARREST NAME / / ID PM ' oN ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT t 2 0 ARREST NAME 1 1/16 /2024 ❑❑PM 0 Unknown work zone type U1 35 x AM T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 488-Ramos.Arely 601 - / / ❑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 0 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 - ` ` '' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C E - (example:shuttle or charter bus):or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O g }} } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or co L.___a____.l _r' I } } } •4. Is used or designated to transport between 9 and 1passengers,includingthedriver. C © for direct compensation(example:large van used fors cific purose):or O L L••_•a-___� A IN - t } } } L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m -- placarding(example:placards will be displayed on the vehicle). —I CARRIER NAME Z ADDRESS 0 ID D CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other Y Not TO Scale , USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 v 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. 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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE