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HomeMy WebLinkAbout2024-00076284 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 II M lI �III1010011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4036 534,3 u, 1 U21 2 4 1 u1 2 U216 U, 1 U2 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00076284 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 12 04 2024 NAM ❑YES ®NO U1 GALVIN DR Elgin09:41 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m 0 !MI N E S W Spectrum Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ® 0 p Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROPtf :TOWED U1 Q Giuntoli. Paul.J. 0 8 / yr 13-UNDER CARRIAGE 10 12! 2 FIRE 0 N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ONM❑UNK VEH. 0 AT CRASH IN ENGAGED 0 99-UNTHER KNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH 0 j$J 1 0 iVi I . Fox Lake I L 60020 0 1 0 FIRST CONTACT 00 7 ; _-5 *rives.See Sidebar Ut ZCM94730 IL 2024 REAR TELEPHONE IL D 0 4T1 K61AK8PU835792 State Farm ❑v Igl N U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same C545614F0113D 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER • RESPONDER 73 Refused ❑Y ® N 2 c p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ My 0 KCV ❑Dv !2 0 0 5 FROM TOWED Civic 2014 00-NONE ,.,_"j z _ x ..--, DUE TO CRASH rg ❑ 2 o Yr 13-UNDER CARRIAGE 10 j ©( 2 FIRE ❑ N U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOPQ3 * X ❑Y El SYSTEM ❑UNK VEH. AT CRASH 99-UNKNOWN Oistraclion value 9 0 POINT OF 6 14 COM VEH ❑ N Ui CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Q. 6 '.-5 •IfYes.See Sidebar ZGilberts IL 60136 0 1 0 EM74808 IL 2025 REAR 0 C IL D 0 2HG FG4A51EH704025 State Farm ❑Y ®N RDEF 7:l EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 1659850SFP13 BAG • $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER 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 0 Y U2 Z N 1 ® 11 4 Illinois.State.o. 2 trees 12,04 l2024 09 43 ®❑AM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1 v 2 0 150 DEXTER CT ELGIN IL 60120 2 99 , , ❑PM ❑Construction R 3 0 El CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 o ® 41 5 ARREST NAME Giuntoli. Paul.J. 11-901-A W1924-000263 / ! El Pm SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility r 2 41 5 ARREST NAME AM T El1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1524 Silva Jose 901 275-Engelke / / ❑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 truckrtrailer -< c ` -' -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C j Mtn _ } (example:shuttle or charter bus):or A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O i. I. } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w 4. Is used or designated to transport between 9 and 15 passengers,including C }--- ----� - ▪ } } } g po pafic p rs,):or the driver, for direct compensation(example:large van used for specific purpose):or wn ▪ l l � L 5. Is any vehicle used to transport hazardous material(HAZMAT)thatrequires any -u placarding(example:placards will be displayed on the vehicle). XI mryawvommo.x CARRIER NAME Z vpoimsaveWw _ __ ADDRESS '� ® r D cwvn»r. rn CITY/STATE/ZIP n Not To Scale 1 MOTOR CARR.ID 0 Interstate El Intrastate O I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 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 White Red u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 0 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 ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE