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HomeMy WebLinkAbout2024-00080553 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 II HI I III 0010II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4036.2.43 u, 1 U29 3 4 4 U1 2 U2 1 U, 1 U299 U, 1 U2 99 5 11 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 202412024-00080553 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn N RANDALL RD El06:20 ® ❑ RELATED ❑Y ®N 12 26 2024 ®AM ❑YES IX]NO U1 -< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION M0Ce !MI N E S W RO al Blvd COUNTY PROPERTY ❑Y 21 N DOORING El #OF MOTOR 0 SLOW 1 (n ® Y Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FROM TOWED U1 0Do le. Lindse M. 1 2 / yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ al < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 rn F 2 4 SYTM❑Y ®NNE❑UNK VEH. O ATCRASH 0 99-U 15-UNKNOWN THER916•TDP3 ,Distraction Value ALGN = V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 Ea 3 O F. Elgin IL 60120 0 1 0 FIRST CONTACT 12 7 . _5 *IIYes.SeeSidebar U1 Z 9 251AC553 IL ' E TELEPHONE IL 0 JTHBK1 EGOB2469397 Talro Ins ❑Y igi N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same PAIL001236050 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES ❑IIIAv 0 i v ❑Dv yr 10 j t2 . 2 FIRE 0 ® U2 C Ti 13-UNDER CARRIAGE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER 911,6•TOP3 0 ® SPDR n 9 9 ❑Y El N ®UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 U1 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 - S .t. 4 COM VEH ❑ ® CO F,,, FIRST CONTACT 6 O7 a 7_ -=)(J•If Yes.See Sidebar C 0 9 9 IUAR O Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 Unknown 0 V 0 N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same Unknown BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1ITELEPHONEI (EMS) (HOSPITAL) 1 3 07 / M 2 4 B 1 0 m / / #OCCS > / / L.), 2 D / / 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 1 12,26 /2024 06 21 ®❑AM 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 C) 2 ❑ 28 99 N 3 0 CITATIONS ISSUED 0 PENDING • + ! - ❑PM- ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5 -a, ARREST NAME / / El PM o N 2111 1 0 • CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 45 r 2 ARREST NAME AM 7 1 / ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 495-Sjodir.Jacob 502 275-Engelke , / El 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 i- i•____r____; I _ combination): r more than pounds(example:truck ortruckrtrarler 1. Has a weight rating10 000 -< INDICATE NORTH o p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C IW, I } (example:shuttle or charter bus):or X ` ` -- I I transporting mployeeslin 5 he courses passengersr thir empld oyment example:employeener I. } } w i ti transporter-usually a van type vehicle or passenger car):or I I 4. Is used or designated to transport between 9 and 15 passengers,including the driver, I. } 1. for direct compensation(example:large van used fors specific purose):or __ _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle)...../ lunmx I XI` D CARRIER NAME —I Z ADDRESS o CITY/STATE/ZIP g 1 I I I I Not To Sc_ate - MOTOR CARR.ID 0 Interstate ❑ Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn 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' T 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 3 TOWED BY/TO. Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE