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HomeMy WebLinkAbout2024-00075542 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 01101100 II M lI 1 fll IOU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003653495 u, 9 U21 2 4 1 U1 5 U2 1 u,99 u2 1 u,99 u2 1 5 10 u, 4 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00075542 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 —n WALNUT AVE Elgin09:55 0 ❑ RELATED ®Y ❑N 11 30 2024 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W WILCOXAVE COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 I83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FRO r TOWED U1 O Unknown. / / Unknown Unknown 00-NONE ©, 12 , DUE TOCRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 VI t230 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _.IL S Ii,_ COM VEH 0 Ea 11 1 0 9 0 FIRST CONTACT 7_: _5 *II Yes.See Sidebar U1 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) unI— known ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 3 99 0 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NMV 0 NCV ❑DV yr 0. 12 Q C 0 13-UNDER CARRIAGE 10 I E FIRE 0 ® U2 C F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 8 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1I COM VEH ❑ ® U1 IN FIRST CONTACT 1 Y i1_, _5 •IfYes,See Sidebar Z Gilberts IL 60136 0 1 0 Q876061 IL 2025 REAR 9 N IL D 4S4BSACC2H3220986 Prgressive ❑Y ®N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X Same 911362645 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER® 3 u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 04 / F 2 3 0 1 0 m / / #OCCS D 71 / / U1 1 m / / 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 ,30 /2024 09 55 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1 2 23 99 N 3 0 ❑CITATIONS ISSUED 0 PENDING • + - 0 PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 z —a ARREST NAME / / ID ' o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT , 30 r 2 ARREST NAME AM T 1 r ❑❑PM El Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ID - ❑AM Workers present? 0 Y 30 1517-Le Cates. Brittany 600 r , ❑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 -< ---.r----; r combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n ~ (example:shuttle or charter bus):or i u"�na+e� r r r 3. Is designed to carry15 or fewer g passengers and operated by a contract carrier i 0 gii . - . transporting employees In the course of their employment(example:employee 73 wrnmcra.fan transporter-usually a van type vehicle or passenger car):or w L L....a__...I. - 4. Is used or designated to transport between 9 and 15 passengers,including the driver, I 1 I t . . for direct compensation(example:large van used for specific purpose):or i i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires O T 'I [111placarding(example:placards will be displayed on the vehicle). XI D CARRIER NAME _. uara _®_ - O anv w... a.scrp. ADDRESS D rn... CITY/STATE/ZIP n Not To Scele , MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rn Xl Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2 TRAILER VIM 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 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE