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HomeMy WebLinkAbout2024-00075112 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets lUI III H IIIl DIII 0110011 1011 1111 OlD DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463643a57 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00075112 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 11 28 2024 ®AM ❑YES ®NO U1 -< PARK ST Elgin09:14 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W N G I FFORD ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 -I igI AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑MUSS ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) .FROM TOWED U1 Q Arreguin.Agustina 0 3 / yr 13-UNDER CARRIAGE ©,I O'.-2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m F 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 15-OTHER 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6.;i�6 4 COM VEH ❑ j$J 1 0 ~ ELGIN N I L 60120 B 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1 Z Z112052 IL 2025 E TELEPHONE IL D Satae farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 1 99 9 Same D644997A2913 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 i v 0 DV !1 9 yf 4 Jeep(after 196;i)ind Cherokee 2011 00-NONE 11 12 t2 "_, DUE TO CRASH ❑ C 2 Ti 13-UNDER CARRIAGE o I 2 FIRE ❑ El U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PONT OF FIRST CONTACT 1 O 7 d 6 L`_5 C•IOMes See Sidebar❑ ® U1 CO F- . . ELGIN IL 60120 0 1 0 EN53895 IL 2025 aR Si)0 IL D 1J4RR4GG8BC530137 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X Elgin Fire 1 99 9 Same E366208E0213B BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 4 11 ,28 /2024 09 30 ®❑AM in a Work Zone? ®N DIRP co 1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) 2 0 23 18 11,28 /2024 09 15 PM ❑ • ❑Construction �F Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ®AM ❑Maintenance U2 ARREST NAME 11,28,2024 09 19 ❑PM 1 ® 11 4 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT N SECTION CITATION NO. ROAD CLEARANCE TIME o El AM U1 25 F 2 El ARREST NAME 1 1 128 12024 09 45 0 PM ❑Unknown work zone type nCf 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 25 435-Mahan. David 301 404 Duffy i , ❑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 -< c ` -- -' I. INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ (example:shuttle or charter bus):or C I [.. * 3. Is designed to carry15 or fewer passengers and operated a contract carrier O -----_; 410 j _ I I I ` } } } transporting employee in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a._..� 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N } } } g po passen rs,includi the driver, — — — — z_d _ _ _ for direct compensation(example:large van used for specific purpose):or O ' L..._a_ _ - l. i. } i. L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires rn T placarding(example:placards will be displayed on the vehicle). ;p I �T ,r , CARRIER NAME Z I — - ADDRESS D Not To Scale I n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other I."---- --: - USDOT NO. ILCC NO. rn XI Source of above z . Form Number 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 TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver 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: 3 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE