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HomeMy WebLinkAbout2024-00074468 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 110 II loll 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY xooa63 4 3 u, 1 U21 3 4 1 U116 U2 1 U, 1 U2 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00074468 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I GALVIN DR Elgin ® ❑ RELATED ®Y 0 N 11 25 2024 ®AM D YES ®NO U1 -< PRIVATE mo /day/yr 11.41 ❑PM FLOW CONDITION M_ 025 ®!MI N E 0 VY ROUTE 72 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NOV ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 0 3 / Kia Motors Cotgportage 2024 00-NONE „ O , DUE TOCRASH ❑ EN 13-UNDER CARRIAGE 10 i : 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 3 <<T1 M 2 SY 15-OTHER 4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2 • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL a 4 COM VEH ❑ Ea 1 0 H 1- HANOVER PARK IL 60133 0 1 0 FIRST CONTACT 12 r: _5 *Ir Yes.See Sidebar U1 ZES96137 IL 2025 REAR TELEPHONE IL D 0 5XYK6CDF4RG215833 GEICO El igiJ N U2 M 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 6129469455 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER t D Y D N O O O Honda Civic 2010' oo-NONE ,t i 1z..-_, DUE TO CRASH ❑ C 2 ... _ 13-UNDERCARRIAGE ta;l 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 `OistraclIon Value 0 POINT OF 8 4 COM VEH D ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR .II 6 �'_ FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar z GILBERTS IL 60136 0 1 0 DP96043 IL 2025aR IL D 0 2HGFA5E59AH701871 ALLSTATE ❑Y ®N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 811844677 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPOND❑Y 0N U1 = ;UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (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 ,25 /2024 11 41 ®❑PM in a Work Zone? ®N DIRP co 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 0 2 28 99 / 0 PM. ❑Construction * Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 a CERRITOS. MANUEL.A. 11-601 w244-1792 / ! PM ' -, ARREST NAME ❑ o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT AM TT 2 ❑ 1 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 30 244-Blomberg. Michael 901 404-Duffy / / ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is . L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } transporter-usually a van type vehicle or passenger car):or 03 < <.__-a-_-_, , 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 0 L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zj D—7 CARRIER NAME Z ADDRESS 0 co CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above 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? ❑ Yes II No ElUnknown A 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m 11 TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray White 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