HomeMy WebLinkAbout2024-00074721 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a645512
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00074721 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
® ❑ RELATED PRIVATE ❑Y ®N 11 26 2024 12,— ❑YES ®NO U1
N STATE ST Elgin mo /day/yr 01:43 ®PM FLOW CONDITION M
010((l /MI N E O W LAWRENCE Ave COUNTY PROPERTY ❑Y Igl N DOORING ❑Y #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
0 6 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 ]$I U2 6 �T1
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL a i 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
ZBL54840 IL 2025 REAR
TELEPHONE
IL D 0 19XFC1 F37GE040215 STATE FARM ❑Y ®N U2 I'IL' 'I
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same 0821413SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.I3 RESPONDER D 0
m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NOV 0 Ixv 0 CIRCLE NUMBER(S) U1 Dv
/2 O O O BMW 323 2000 00-NONE ,� ' , DUE TO CRASH ❑ p�( 2
o - 13-UNDER CARRIAGE 11_ t2 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 t6-TOP
3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S I .;, 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 7 Q 1_, _5 •If Yes,See Sidebar C
ELGIN IL 60120 0 1 0 EG57929 IL 2025 I Si)0
IL D 0 WBABM3340YJN64196 AMERICAN FAMILY INSURANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 411080084662 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPONDER❑Y u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 02 /
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D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,26 /2024 01 43 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
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2 0 20 99 / / 0 PM ❑Construction *
" 3 0 xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
a MORENO.VERONICA 11-709-A w244-1793 / / PM
-, ARREST NAME ❑
oN 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
T 2 0 ARREST NAME AM
7 / / pM 0 Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
0 Y 30
244-Blomberg. Michael 601 272-Bajak / / ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
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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
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-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
21.
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CARRIER NAME Z
ADDRESS 0
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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
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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 Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE