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HomeMy WebLinkAbout2024-00079641 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 III fl UI 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a672017* u, 1 U21 3 4 1 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 4 10 u1 3 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A 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$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 2024I 2024-00079641 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN RANDALL RD Elgin06:58 ® ❑ RELATED ®Y 0 N 12 20 2024 ❑AM ❑YES El NO U1 '< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W W HIGHLAND G H LAN D AVECOUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El 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 IR N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGED AREA(S) FROf4T TOWED U1 Duran.Anthony 7 / yr 13-UNDER CARRIAGE © IE ,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED ❑ 0 U2 4 in M 2 8 ❑Y ®SYSNEM DUNK VEH. 0 AT CRASHD 0 99-UUTHER NKNOWN 9 16.70P 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;.il S _5 *ItYes.See Sidebar U1 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7 ,_ Z Streamwood IL 60107 0 1 0 220865C IL 2024 Is TELEPHONE IL 0 1 FTBR1X86RKA81698 Starr Indemnity ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 DONLEN TRUST LSR 1000198177231 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 EON. 0 EWES 0 /1 9 9 8 Cadillac Escalade 2005 00-NONE 0-1 QI'-O DUE TO CRASH rg ❑ 2 x o yr 13-UNDER CARRIAGE 10( ) 2 FIRE 0 ® U2 C F 2 8 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16-TOP 3 9 0 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value i1� -4 COM VEH 0 ® t N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 8 7 B .5 • = UNION IL 60180 0 1 0 DK43237 IL 2024 I If Yes.See Sidebar U1 CO 0 C IL D 0 3GYFK66N75G111975 Unknown ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same Unknown BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 08 / D / / 3 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12/20 /2024 06 58 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 06 28 / / 0 PM ❑Construction >F Z 3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM El Maintenance U2 o1 ® 11 1 ARREST NAME Duran.Anthony 3-707 485324 / / ❑PM ' I$[CITATIONS ISSUED 0 PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME AM'• ❑ r 2 0 ARREST NAME Duran.Anthony 11-902 485323 12120 /2024 07 50 ®PM 0 Unknown work zone type U1 50 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 485-Quintana.Josue 602 21 ( /2 /24 09 00 ❑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 -< i- ;.__-_r_-__1 A combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C L I I I I I I } (example:shuttle or charter bus):or 4141 III Not To Scale 0 L A II 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O 1�I I I-► I I I } } . transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w C L }-----}----; - I. } } 1 •4. Is used or designated to transport between 9 and 15 passen including the driver, II I I I I for direct compensation(example:large van used fors specific purose):or O L L____a____� / \ e _ L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ,� � 4 placarding(example:placards will be displayed on the vehicle). XI r g4 CARRIER NAME z 11MI1 ADDRESS Drn t I t I t l CITY/STATE/ZIP C MOTOR CARR.ID 0 Interstate 0 Intrastate 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'; 0 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 Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE