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HomeMy WebLinkAbout2024-00073974 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 01011101000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003645440* u1 1 U21 1 1 1 UI 5 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00073974 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I ® ❑ RELATED ❑Y ®N 11 22 2024 ❑AM ❑YES ®NO U1 -< CENTER ST Elgin05:52 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI 0 !MI N E S W East Chicago St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 co ® g Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Os Ina Marin. Paola.A. 1 2 / yr 13-UNDER CARRIAGE ©i ! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 THERDISTRACTED 0 ]$I U2 0 rI1 F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TDP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�S �i 4 COM VEH ❑ j$J 1 0 ELGIN IL 60120 0 1 0 FIRST CONTACT 11 7_; __5 *Ilsees.SeeSidebar U1 Z DJ60942 IL 2024 REAR TELEPHONE IL D 0 3D4PG4FB4AT254747 Kemper ❑v ®N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 12RA000002373 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV yr 12 .. 13-UNDERCARRIAGE 10;i 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i S i.�,_4 C.OM VEH ❑ ® U1 CO FIRST CONTACT 1 7 _,__5 •IfYes.See Sidebar C ELGIN IL 60120 0 1 0 EN93880 IL 2024aR Si)0 IL D 0 1 G KKN KLSXLZ201556 First Chicago Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same ILS10299910-00 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 04 / :A / / UI 2 D / / 2 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 ,22 /2024 05 52 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 0 2 26 11,22 /2024 05 52 PM ® • ❑Construction * Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 - N a ARREST NAME 11/22/2024 05 55 ®pM ' , 1 ® 0 Utility 1 1 1 0 CITATIONS ISSUED ❑PENDING SLMT o SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM r 2 El ARREST NAME 1 1/22 /2024 04 15 ®PM El Unknown work zone type U1 30 n 7 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 488-Ramos.Arely 1o1 334-Fries , / ❑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 INLVED,USE SR 1050A ADDITIONAL UNITVOS 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 -' J r INDICATE NORTH 0 combination)or P3 Highlald?Av.. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i — — — — — — — — - } (example:shuttle or charter bus):or n X I I I 3. Is designed to carry15 or fewer passengers and operated a contract career O }_---A----i - }} } transporting employee � �In the course of their employment(example:employee � I- 73 transporter-usually a van type vehicle or passenger car):orco C L }-----}----J. I © - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose):or O L L____a____� } I I t i i t 5. Is any vehicle used to transport hazardous material(HAZMAT)thatrequires m I placarding(example:placards will be anyisplayed on the vehicle). —1 CARRIER NAME Z El ADDRESS O EMNICpo75Q. cCITY/STATE/ZIP0g Not To Scale I I I I MOTOR CARR.ID ❑ Interstate ❑ Intrastate 1 1 r 1 1 I I I 0 Not in Comm./Govt. Not in Comm./Other 0 --- '-1 USDOT NO. ILCC NO. <m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 co 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 Silver Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE