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HomeMy WebLinkAbout2024-00077780 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100001 fl 10111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a6 2'D29 u, 9 U21 2 1 8 U1 2 U2 1 U, 1 u2 1 U1 1 u2 99 1 10 u1 3 U2 3 *P 0119�K INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 El ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2024I 2024-00077780 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I BOWES RD Elgin ® ❑ RELATED PRIVATE ®Y 0 N 12 11 2024 ❑AM ❑YES 0 NO U1 mo /day/yr 12:10 ®PM FLOW CONDITION m 231°9p/MI NOS W South Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 (g)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 4 n FOR DAMAGEDAREA(S) FROf4r TOWED U1 Q Rupert.Zachary.S. 0 1 / yr 13-UNDER CARRIAGE ©10,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 4 rn M 2 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH ❑ Ea 1 0 I . FIRST CONTACT 11 7_:—__;__5 *Ilsees.See Sidebar U1 Z Chicago IL 60647 0 9 FB14819 IL 2025 REAR TELEPHONE IL D 0 JTEZU5JR6J5182082 none ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same none 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused El El 2 c N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 use 0 NCv 0 DV 1 9 9 2 Hyundai Sonata 2015 00-NONE 0. Q1-_, DUE TO CRASH ❑ 2 x 0 Yr 13-UNDER CARRIAGE 10( l 2 FIRE 0 ® U2 C M 2 5 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il 6 I1:, 4 COM VEH ❑ ® U1 W FIRST CONTACT 11 7� __5 •(ryes.See SidebarC H ELGIN IL 60123 B 1 E922393 IL 2025 I 0 N M IL D 0 5NPE24AF8FH2O5068 All State ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 = Same 932733476 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOS) (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 ❑Y U2 Z N 1 ® 11 1 12,11 ,2024 01 55 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T 0 2 ❑ 2 99 + / ❑PM. ❑Construction R , 3 ❑ $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Rupert.Zachary.S. 3-707 320-6327 / / ❑PM o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT r 2 ❑ 45 ARREST NAMEAM c- T / r ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 540-Dykema.Tracy 391-Jacobucci 01 ,07/2025 01 30 ®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 Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` --I -' r INDICATE NORTH combination):or —I r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver _ } (example:shuttle or charter bus):or X A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or C L L.___a____� 4. Is used ordesi natedtotrans transport passengers,including N } } } g po fic p rs,includi the driver, I for direct compensation(example:large van used fors cific purpose):or O __ l. I I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires If placarding(example:placards will be displayed on the vehicle). XI —I I k.."-- CARRIER NAME Z llatolodtmnall ADDRESS 'n r n CITY/STATE/ZIPC II I - MOTOR CARR.ID 0 Interstate ElIntrastate 5 ' I I I ❑ Not in Comm./Govt. Not in Comm./Other �I. --- --1 - USDOT NO. ILCC NO. rn 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 E 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 co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black White 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: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE