HomeMy WebLinkAbout2024-00070985 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets - 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2024I 2024-00070985 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
N RANDALL RD Elgin07:08
® ❑ RELATED 0 Y ®N 11 07 2024 ❑AM ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
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®24 /MI N E S W BigTimber Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
O Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
/ / FOR DAMAGEDAREA(S) FRO TOWED U1 Q NT
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 M9 9 Y El N ®UNK VEH. AT CRASH SYSTEM IN 9 ENGAGED 9
❑ ®-
15-OTHER UNKNOWN 9 ,6.TOP 3
`Distraction Value 9 x
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it s .i COM VEH 0 Ea
1.... FIRST
1 0 FIRST CONTACT 99 7 : AR _5 *II Yes.See&debar U1 0
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
NONE El ®N U2 I—
i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same NONE 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
> RESPONDER D
❑Y ® N 99 0
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N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 I v 0 DV
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!1 9 yf 8 Honda Pilot 2013 00-NONE 1i_' 12._0 DUE TO CRASH 0 ® 2 x
o 13-UNDER CARRIAGE I FIRE ❑ ® U2
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F 2 4 ❑Y ElElSYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 9 9 X
N UNK VEH. AT CRASH 99-UNKNOWN *0istraellon value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 FIRST CONTACT 2 -iI 6 ii, COM VEH El ® U1 CO_, •
n ELGIN IL 60123 0 1 0 AM23609 IL 2020 AR
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D 7 _5 IfYes,See Sidebar
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IL D 0 5FNYF4H51DB042774 Farmers Insurance ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Hilgart. Matthew.T. 518480146 BAG $
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)
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1 0
EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 11 /07 /2024 07 08 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5
T 2 0 v 20 18 / / ❑PM ❑Construction *
Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM '
1 ® 11 1 ❑CITATIONS ISSUED ❑PENDING SLAT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
ElUtilit y
❑AM U1 55
T 2 El ®ARREST NAME 1 1/07 /2024 07 08 PM ElUnknown work zone type
x T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
❑AM Workers present? ❑ 55
2 2 3 0
1539-Vargas. Miguel 500 / / ❑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
{���' mom„ ; 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
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r INDICATE NORTH �mb natbn)or p3
® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- I. } } 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 rtbetween9and15passengers,includingthedriver,
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"°'mac } } for direct compensation(example:large van used for speific purose):or
L____a____� —> L L L 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ,Zmt
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CARRIER NAME Z
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ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
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I I , I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
� --- --1 - USDOT NO. ILCC NO. m
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Source of above z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
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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
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Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE