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HomeMy WebLinkAbout2024-00073766 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 4 Sheets 01111101111 101101100 II ifi . dill DII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X60363.1 3 u, 2 U21 3 4 1 U1 U2 1 U1 1 U2 1 U1 1 U2 1 4 11 U, 1 U2 1 *P 0 1 1 9 INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2024I 2024-00073766 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ❑Y ®N 11 21 2024 DAM ❑YES ®NO U1 N RANDALL RD Elgin08:09 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m !MI N E S W Royal Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ' ® y Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑MN ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) NT TOWED EN U1 0Sa o.J afire Honda Accord 2006 00-NONE 2 0 DUE TO CRASH ❑ NAME(LAST,FIRST,M) g y mo yr 13-UNDER CARRIAGE ©,I :: FIRE 0 5 r< STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rl M 2 SYTM IN ENGAGE15-OTHER 8 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 916•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 Ea 1 0 ~ Rockford I L 61103 B 1 0 FIRST CONTACT 12 7 ; _-5 *Irves.See Sidebar U1 ZDR89531 IL 2024 ' E TELEPHONE IL 1 HGCM66366A002510 Safeway Ins Co ®Y 0 N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 3735576I LPP001 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Provena St.Joseph ❑Y El 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row 0 i v 0 Dv !1 Yr 9 9 2 Honda CRV 2025 00-NONE 'o,1 t2 c,�2 FIRE DUE OCRASH 0 ® U2 2 C o 13-UNDER CARRIAGE Ti F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X 0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraglon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i S .t. 4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,_=Q,OS C. If Yes.See Sidebar C ELGIN IL 60124 B 1 0 EX73199 IL 2024 AR Si)0 Z IL D 5J6RS4H48SL010125 State Farm Ins Co ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Ayala.Angelo.A. 1365710SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y / ,, U1 1 D 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 ,21 /2024 08 09 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 28 99 11,21 ,2024 08 09 ®PM ❑Construction >F R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Sago.Jyaire 11-601-Ax 751646 11,21 ,2024 08 14 ®PM SLMT CITATIONS • ISSUED ❑PENDING jg Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• y l r 2 El ARREST NAME Sago.Jyaire 3-707 751644 11,21 ,2024 08 20 0 PM El Unknown work zone type U1 50 2 2 3 El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 481-Rodriguez. Hannah 901 397-Jones 12 , 18,2024 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�__ _r____; el 1. Has atWn weight htrating more than 10,000 pounds(example:truckortrucktrailer INDICATE NORTH 5311 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r r (example:shuttle or charter bus):or X jt I mat To scare I ' 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O t N - } } } transporting employees In the course of their employment(example:employee X Re I transporter-usually a van type vehicle or passenger car):or w } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N L. for direct compensation(example:large van used for specific purpose):or o L L____a____.I t ` _ t l. I. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). Bid . 1 v I If - CARRIER NAME Z r r -1- 1 ---1 [ ADDRESS 'n D 0 CITY/STATE/ZIPg - i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate 5 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 USDOT NO. ILCC NO. m XI Source of above z . • m 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? 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 Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m 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 Black Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE