HomeMy WebLinkAbout2024-00058258 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
I01101100MM III III ifi 000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553065
u, 2 U2 1 1 1 U, 8 U2 1 U, 1 1_12 U, 1 U2 1 5 9 U1 14 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 2024I 2024-00058258 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I
® ❑ RELATED ®Y ❑N 09 12 2024 ®AM ❑YES ®NO U1
S CHANNING ST Elgin 01:05
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W LAUREL ST COUNTY PROPERTY ❑Y N N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
T TOWED U1 Q
FOR DAMAGEDAREA(S) FROM
Sanders. Dominique.J. 1 2 /
yr 13-UNDER CARRIAGE 16) 2 , 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTHER TAL(ALL) DISTRACTED 0 N U2 2 M1206 F 2 8 ❑Y SYSNTEM DUNK VEH. 0 AT CRASH 99-UUNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_6 1i.4 COM VEH 0 N 1 O
F. FIRST CONTACT 12 7 ;—__, - *I(Yes.See Sidebar U1
Z Joliet IL 60431 B 1 0 CL27330 IL 2023
TELEPHONE
IL D JM3ER29L670137398 American Freedom ❑Y IlN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1
Same 12241095100 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
yr 12,,
Jo 13-UNDER CARRIAGE 10) I 2 FIRE 0 N U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 N SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 9
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraetlon Value U1
POINT OF s ( 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II S LL_ COM VEH 0 N CO
FIRST CONTACT 6 Y__{_0 _s •IfYes,SeeSidebar
H CA68496 IL 2025 REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5N1 DR2MM6KC632742 Safeway Insurance ❑Y N N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Aguilar. Francia. E. 3466085ILPP007 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI j(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 05 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 N 18 1 09,12 /2024 01 05 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 0 08 28 09,12 /2024 01 05 ❑PM ❑Construction *
R O 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ®AM ❑Maintenance U2
—a, ARREST NAME Sanders. Dominique.J. 11-601 751579 09,12/2024 01 10 ❑PM SLMT
o u 1 ® 11 1 N CITATIONS ISSUED 0 PENDING TIME ' 0 Utility
o N SECTION CITATION NO. ROAD CLEARANCE ❑AM 30
t 2 El ARREST NAME Sanders. Dominique.J. 11-501-A-2 751578 , / ❑pM El Unknown work zone type U1
2 2 3 0 -
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
1504-Real, Hilario 301 385-Olsen 10 ,08,2024 09 00 ❑PM Workers present? ®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.
. 0
r 1----1--•--, , „ ; 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
} } ' ; } INDICATE ARROW NOTH combination):or .Z�1
52 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
A e 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I. } } 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 C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
— — — — Pe ( P 9 Pe or O
L t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I— - placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS 0
V)
C)
CITY/STATE/ZIP g
_ MOTOR CARR.ID El Interstate El Intrastate
1 I r 1 0 ❑ Not in Comm./Govt. 0 Not in Comm./Other
1 1 - '
USDOT NO. ILCC NO. m
_Not To Scale) XI
Source of above z
. • m
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
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
Maroon Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE