HomeMy WebLinkAbout2024-00056494 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00056494 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 17 mS MCLEAN BLVD El 03:16
® ❑ RELATED ®Y 0 N 09 05 2024 12,— ❑YES El NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT/MI N E S W LI LLIAN ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ RED 22 PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FRO 1 TOWED U1 O
NAME(LAST,FIRST,M) mo
/1 9 9 4 Unknown Unknown 00-NONE 0 O i" , DUE TOCRASH ❑
13-UNDER CARRIAGE 10. EN
I , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 rn
M 5 3 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 j$J 1 0
c ZFIRST CONTACT 12 7_; __5 *uyes.See Sidabar U1
ELGIN IL 60123 B 1 0
TELEPHONE
IL D K6F0002480 N/A ❑Y ❑N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 64 1 Same N/A 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 0
m N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑New ❑NCV ❑DV
!1 9 8 3 Ford E350 Super Duty 2004 00-NONE ,�_"j 12 -_, DUE TO CRASH 0 2
0 13-UNDER CARRIAGE to 2 FIRE ❑ ® U2 C
c ®
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16_TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN O `Distracter)Value U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
�i 4 COM VEH D ® CO
I� FIRST CONTACT 5 Y �_,-`-C)•If Yes.See Sidebar C
60110 0 1 0 CN31859 IL 2025 I 0 Si)
IL D 1 FBNE31 L64HB13240 PROGRESSIVE INS CO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 64 1 Same 985159062 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)
2 3 08 / F 2 4 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 13 4 09/05 l2024 03 16 ®pm in a Work Zone? ®N DIRP co
1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 28 99 09/05 /2024 03 26 ®PM El Construction
>F
R O 0 xi CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM 0 Maintenance U2
-a, ARREST NAME NGUYEN.TONY. N. 11-601-Ax 481000201 09/05/2024 03 30 ®PM CITATIONS ISSUED PENDING SLMT
1 ® 13 1 ❑ • Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME Ely
0 AM
F 2 ElARREST NAME 09/05 /2024 03 45 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
481-Rodriguez. Hannah 602 334-Fries / / ❑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••--, , F
A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1 I Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- } ; T I T - INDICATE NORTH
---. -----; 1,
N col. ):or —I
i_ i.. -:. j I 1 -- p0
^aA a"`.- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
}
A 4 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____.I 4. Is used ordesi natedtotrans rtbetween9and15 passengers,includingN
} } for direct com nation exam I lar a van used for s �cifice ur o )orthe driver,
Pe ( P 9 Pe P pose):or O
L L____a____.I MIN 1
Untt2 - t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
♦ D
CARRIER NAME Z
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ADDRESS 0maI ` I 1 ui.»et w
n
4, I I ♦ CITY/STATE/ZIP g
1 Mn� MOTOR CARR.ID 0 Interstate 0 Intrastate 5
eiwO
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes II No ❑ Unknown 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE