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HomeMy WebLinkAbout2024-00077621 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 0000 0100 DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY XoG36.8253 u, U21 1 1 1 U, U2 1 U, 1_12 1 u, U2 1 5 1 U1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY El g500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑g501-g1,500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00077621 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH r7 ® ❑ RELATED PRIVATE ❑Y ®N 12 10 2024 ❑AM ❑YES ®NO U1 -< KIMBALL ST Elgin mo /day/yr 06:38 ®PM FLOW CONDITION M 020 0/MI N E S © N GROVE St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 -I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 0 DRIVER ❑ PARKED ❑DRIVERLESS Ig) PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Ho Randolph. L. 0 7 / yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 4 rn M SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _ ❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN S lL a ji COM VEH 0 0 1 4 `Distraction Value ALGN r POINT OF CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ~ ELGIN IL 60123 A FIRST CONTACT 00 7_; _5 *II Yes.See Sidebar U1 0 2 REAR 2 Z TELEPHONE IL 0 Y 0 N U2 1- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 2 47 1 1 r o HOSPITAL(TAKEN TO) INCIDENT IF`' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Provena St.Joseph ❑Y ® N Eg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NCv ❑Dv CIRCLE NUMBER(S) U1 Yr 13-UNDER CARRIAGE 10( ) FIRE 0 ® U2 C ij M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI . -4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 7 -5 •• •IfYes,See Sidebar H ELGIN IL 60123 0 1 0 E234415 IL 2023 IL D 0 4T1 BF1 FK1 EU471432 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 982541967 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) W 12 / M m / / S#OCC D Pj / / UI ' 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 ® 12 1 12/10 /2024 06 38 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AMU1 v 2 26 18 12/10 /2024 06 38 ®PM 0 Construction >F 4 R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME Hopp. Randolph. L. 11-1003 399003656 12/10/2024 06 42 ®PM SLMT o U1 ® 12 1 CITATIONS ISSUED 0 PENDING o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility r 2 0 ARREST NAME Hanly.John. E. 11-709-A 399003655 12/10 /2024 09 51 ®PM 0 Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1507-Ruiz.Alondra 102 223-Hughes 01 ,21 /2025 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. A. A CMV is defined as any motor vehicle used to transport passengers or property and: Z N 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< i- }--_.r-_--; - combination):or —I J Not To Scale INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X L A 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 w L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or ---i ronoerma O __ i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt -I IIICARRIER NAME Z ura O - __ ADDRESS D — .�` — — o n CITY/STATE/ZIP g - MOTOR CARR.ID 0 Interstate El Intrastate I I T I I I 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above Z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m 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: TOWED BY/TO. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE