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HomeMy WebLinkAbout2024-00073737 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 II lfl 011111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403637075 u, 9 U21 3 4 2 U1 2 U2 1 U,99 U2 1 U1 99 U2 1 5 10 u, 3 U2 11 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00073737 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 N STATE ST Elgin 04:56 ® ❑ RELATED ' V 0 N 11 21 2024 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 Co ❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FROM TOWED U1 I� Unknown.0. / / Unknown Unknown 00-NONE ©, • >2 �/DUE TOCRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 O < 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916-TOP 3 0 ' _ ❑Y ❑N CO UNK VEH. AT CRASH 99-UNKNOWN 6 4 `Detraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i _6 'I C.OM VEH 0 )g! I 0 I— FIRST CONTACT 12 7__:1_ _,__5 *II Yes.See Sidebar U1 0 1 0 UNKNOWN REAR 2 Z _ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED I 1/ Unknown ❑Y ❑N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Unknown 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER .5D Y°®N 0 m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv Yr/1 9 6 2 General MotorTerrain 2015 Do-NONE ,1_` t2 "_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 21I 2 FIRE El 21 U2 cXj v' M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN )1I� C `Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT NT OF 99 7. �'�.6 C.OMy gee SH idebar❑ ® U1CO C Z Crystal Lake IL 60014 0 1 0 BQ54282 IL 2025 REAR 0 Si) Z IL D 0 2GKALREK9F6224298 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I = Same 3340061 sfp13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 11 ,21 l2024 04 56 ®pm in a Work Zone? ®N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 4 n T v 2 0 2 18 1 / 0 PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 —a, ARREST NAME / / El PM ' o u ® 11 `1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT AM45 T1 2 ❑ / 1 ❑❑PM 0 Unknown work zone type U1 ARREST NAME n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 1545-VanEycke. Brier 501 / / ❑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. J I IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. A CMV is defined as any motor vehicle used to transport passengers or property and: Z .. �,.... �M91r'78e1 I z 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer i- -'- -� I ( INDICATE NORTH combination):or Not TO Sce.Io I ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or r r r X , Itill 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 l- <.___A..•—I ,,,.1 - y } } } transport) employees in the course of their employment er a t transporterg-uslly a van vehicle or (example:employee i. <.___a.._.J 1�� - •} } } 4. Is used or designated to transport between9a d15nger rpassen rs,including the driver. C C�• r , for direct compensation(example:large van used for specific purpose):or O L L-___ -...� Q iLi., ._, - l. i. any 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m — — placarding(example:placards will be displayed on the vehicle). —1 CARRIER NAME Z ADDRESS T. 0/� C) CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate I r I I ❑ Not in Comm./Govt. Not in Comm./Other0 ; _Y_._..; USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m v 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 Red 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