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HomeMy WebLinkAbout2024-00072806 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 II lfl III 1I 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a637O02 u, 2 U2 1 1 1 U1 4 U2 U, 1 u2 U, 1 U2 4 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 1 VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2024I 2024-00072806 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 17 2024 ®AM ❑YES ®NO U1 TECHNOLOGY DR Elgin mo /day/yr 00:03 ❑PM FLOW CONDITION M ®50 ® © COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl)!MI N E S Galvin Dr WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM T TOWED U1 Q y Bakhsh. Raymond. R. 1 2 / yr 13-UNDER CARRIAGE ta.l 2 , 2 FIRE 0 NI < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 23 U2 rn M 2 6 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UNKNOWN THER9 t6•TOP 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 4 .4 C.OM VEH ❑ El 1 0 REAR Z 60102 0 1 0 DS16212 IL FIRST CONTACT 12 Y __s ves.See Sidebar Ut TELEPHONE IL C 0 1 G 1 FF1 R77P0111341 Geico ❑Y ®N U2 M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Bakhsh. Rohail 6163190330 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou 0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 yr 12 _ 71 o 13-UNDER CARRIAGE 10.i t, 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 Ij._5 CIO es See SidebarEH ❑ C CO F` REAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 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 995 < RESPNDER❑YO❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI :(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 1 3 09 / M 2 6 B 1 0 U2 I71 / / #OCCS > / / UI 2 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 5 Communications Test Design Incorporation Two trees 11 ,17 ,2024 00 04 ®❑pM 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 v t 2 0 2200 GALVI N DR ELG I N IL 60124 28 99 11!17 ,2024 00 12 ❑PM ❑Construction R O 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ®AM ❑Maintenance U2 -a, ARREST NAME Bakhsh. Raymond. R. 11-601 751603 11,17/2024 00 24 ❑PM SLMT o U 1 0 MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N 0 AM 20 t 2 El ARREST NAME Bakhsh. Raymond. R. 11-503-A-1 751605 ! / PM 0 Unknown work zone type U1 n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 1524-Silva,Jose 901 12 ,23,2024 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 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< ` ` --I -' r INDICATE NORTH combination):or -I 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J (example:shuttle or charter bus):or n r rX I- I- A 3. Is designed to carry 15 or fewer passengers and operated by 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 CO L L.__-a__-_J 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, vaa Pe ( P 9 Pe or o L i l. i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m pMcarding(example:placards will be displayed on the vehicle). XI unxrrr - . 1 OeP*''°Of CARRIER NAME Z __ ADDRESS 'O T. Not To Scale CITY/STATE/ZIPg MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . 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 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 Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE