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HomeMy WebLinkAbout2024-00073439 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 II lfl 0010111110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a63 2242 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY [8]OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00073439 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 11 20 2024 ®AM ❑YES ®NO U1 —< LARKIN AVE Elgin09:09 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m 15 !MI N E s South Lyle Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (/) ® © y Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) 0 3 ! yr 2010 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M F 2 SY4 ❑Y ®SNE M❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�6 4 COM VEH 0 Ea 1 0 F. FIRST IL FIRST CONTACT 12 7_;—_,__5 *IIYes.See Sidebar U1 Z SOUTH ELGIN IL 60177 B 1 0REAR TELEPHONE IL D KM H DU4AD5AU039400 USAA ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 007495346C71034 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Provena St.Joseph ❑Y ❑ N 271 N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 i v ❑DV !1 9$7 Hyundai Accent 2013 Do-NONE 1t"i 12..-_, DUE TO CRASH ❑ C 2 o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraebon Value 9 0 POINT OF 8 i 4 COM VEH D ® u1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 6 7 -�IOS •ItYes.See Sidebar C Bartlett IL 60103 0 1 0 EY83827 IL REAR 0 Si) IL D KMHCU5AE4DU093141 Progressive ❑Y ®N RDEF ZI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 986139879 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 ® 11 1 11 ,20 /2024 09 09 ®❑pm 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 0 2 ❑ 28 03 { ) ❑PM ❑Construction * Z3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 a NORDTVEDT.SUSAN. E. 11-601-Ax W410000677 / ! PM —, ARREST NAME ❑ oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT t 2 El AM NAMEAM x- T / / ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 410-DeLeon.Jessica 602 272-Bajak / / ❑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 Lyle I ve 1 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< i- }-- --I-- --' I r INDICATE NORTH combination):or t ■ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ i.. -:. j ■ i. e. r r (example:shuttle or charter bus):or 0 r ��� •I.2 1 (u-M_i) - 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 — ?A,re - - - - transporter-usually a van type vehicle or passenger car):or CD LarL L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L i L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt —1 — — — — — — CARRIER NAME Z ADDRESS 0 w 1 I I ' N.lb ay.w 1 CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate 0 I I T . ._ I I ❑ Not in Comm./Govt. Not in Comm./Other ; -- -_ USDOT NO. ILCC NO. 0 XI Source of above Z IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No = TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE