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HomeMy WebLinkAbout2024-00074440 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II lfl 11/100011 HIDRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a637.84 u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 1 U2 3 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2024I 2024-00074440 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 71 ® ❑ RELATED ®Y 0 N 11 25 2024 El ❑YES ®NO U1 -< N RANDALL RD Elgin 09:12 _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION ITl FT!MI N E S W ROYAL BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 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 0 C) T TOWED U1 FOR DAMAGEDAREA(S) FROM EN 0Batsukh.Ganzori 0 4 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 jgj U2 0 r11 M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ❑SNE®UNK VEH. 9 ATCRASHD 9 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 4 COM VEH ® ❑ 3 0 ~ Naperville IL 60564 0 1 0 FIRST CONTACT 12 7_:, __5 *I(Yes.See Sidebar U1 Z P P1073675 IL 2025 REAR TELEPHONE IL A 4V4NC9EJ4BN298131 Acord ❑Y ®N rTl U2 r in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a Mago Tour Inc A0223501001 1 I— t HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 21 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 Ixv 0 Dv !1 9 yf 5 Land Rover Range Rover 2016 00-NONE 0.,. z j--O DUE TO CRASH rg ❑ 2 73 0 13-UNDER CARRIAGE 6 I ©(. 2 FIRE ❑ ® U2 C F 2 8 SYSTEM IN g ENGAGED g 15-OTHER 9.16•TOP 3 X ❑Y ❑N IN UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 11:, COM VEH 0 ® U1 CO FIRST CONTACT 11 7�. _5 •If Yes.See Sidebar Z SOUTH ELGIN IL 60177 A 1 0 DP90281 IL 2024 I g n IL D SALWR2PF6GA114801 Allstate ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Niaz.Yaseer 802307812 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL) U1 1 D / / 1 0 co EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z El AM N 1 ® 11 4 11 ,25 l2024 09 12 0 PM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 25 28 , ! 0 PM ❑Construction * Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 6 ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Batsukh.Ganzorig 11-305-A 410000679 / ! ID Pm SLMT o N u ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility 45 t 2ARRESTNAMEAM 7 ❑PM 0 Unknown work zone type U1 El 1 / ❑ 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 410-DeLeon.Jessica 602 272-Bajak 12 , 17,2024 01 30 ®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 truck trailer -< i- }----'-- --' I I I I - } INDICATE NORTH combination):or ` 8 I I I I 8 X _ 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or n r r •` ` A N J \ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L 4. Is used or designated to transport between 9 and 15 passengers,including y }--- ----; - •} } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or L t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D ii ,, placarding(example:placards will be displayed on the vehicle). XI D CARRIER NAME Mon Pride Express Inc Not To so.l. I ADDRESS 1384 BRAYMORE CIR I I I I D CITY/STATE/ZIP Naperville 1 IL/60564 MOTOR CARR.ID El El Intrastate I I T0 Not in Comm./Govt. 0 Not in Comm./Other ;---------; I I I I - USDOT NO. 2999849 ILCC NO. C Xl 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'7 ❑Yes ®No 2 TRAILER VIN 1 1 UYVS2534DM713532 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ® ❑ 0 Z TRAILER 2 0 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. Z White Maroon u 1 TOWED • TOTAL VEHICLE LENGTH 75 ft. NO. AXLES 5 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: 3 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE LOAD TYPE Arties/Impound Lot Garage • —