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HomeMy WebLinkAbout2024-00076456 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 01101100 II M lI 1011100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a653486 u, 9 U2 1 1 1 u, 2 U2 1 U,99 1_12 U,99 U2 1 5 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00076456 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n 255 S GROVE AVE El In01:55 ® ❑ RELATED ❑Y ®N 12 05 2024 ®AM ❑YES El NO U1 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m _ COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I &RUN ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N n / ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 0 Unknown.O. Unknown Unknown 00-NONE it. t2 , DUE TOCRASH ❑ VI NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 �. 2 FIRE ❑ IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m 9 9 Y ❑N ❑UNK VEH.SYSTEM IN ❑ ENGAGED AT CRASH 15-OTHER 99-UNKNOWN Distraction Value 916.70P�3 _ ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ij 6 �I COM VEH 0 0 1 n 0 9 FIRST CONTACT 99 Y ;1L-_;_OS •II Yes.See Sidebar U1 0 c REAR Z E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 lii Unknown ❑Y ❑N U2 I— 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 IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 99 ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PEO 0 PEOAL 0 EWES 0 iiuv 0 KCV 0 DV yr 0 Q -1 ❑ ! l 2 73 C ©-UNDER CARRIAGE 10 Ic 2 FIRE 0 El U2 Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 9 X a ❑Y ®N D UNK VEH. AT CRASH 99-UNKNOWN `Oistrac) n Value POINT OF S ) ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR}._ C. VEH ❑ ® CO F„ FIRST CONTACT 11 7 , _5 •If Yes,See Sidebar ART6141 WI 2024 REAR 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 19XFL2H81 PE002834 State Farm Insurance 0 Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0245027-SFP-49 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPOND❑Y 0N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 5 12,05 /2024 01 55 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 18 18 N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ❑PM, El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 z —a, ARREST NAME / / ❑PM ' o N 1 ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 15 r 2 0 ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 15 359 Williartson. Linda 07 , , 0 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 e---•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 INDICATE NORTH combination):or -I cn.davrrt,.rs� � +o.et BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } urmrFVEL - } (example:shuttle or charter bus):or ` A EN o 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier i - }} } transporting employees In the course of their employment(example:employee X...l. ill I I I I I I transporter-usually a van type vehicle or passenger car):or w I. 4. Is used or designated to transport between 9 and 15 passengers,includingwwjt } for direct compensation(example:large van used for specificpurpose):or [he driver. Pe ( P 9 Pe or O PA.:I Hill } } I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p 9`' —DI al" CARRIER NAME Z ADDRESS 0 Oaavrrin.vmmra,.r . n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ;____Y____1 - USDOT NO. ILCC NO. m XI Source of above z . 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 Red Silver 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE