HomeMy WebLinkAbout2024-00058192 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00058192 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :7
BIG TIMBER RD Elgin 07:37
® ❑ RELATED ®Y 0 N 09 11 2024 DAM ❑YES ®NO U1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 Cl)
❑ 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
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 Mlles 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
0 2 /
yr 2009 13-UNDER CARRIAGE } O FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0U2 00 <<T1
M 2 8 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER 0916•TOP3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1a 4 COM VEH 0 j$J 1 0
F. FIRST CONTACT 12 7 . , _5 *II Yes.See Sidebar U1
Z Streamwood IL 60107 0 1 0 Q724663 IL 2025 Is
TELEPHONE
IL D 1 G 1 ZK57719 F157704 MAGNUM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 12240295801 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Sherman ❑Y El 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL ❑EWES ❑NOV 0 i v ❑Dv
/1 9 yr 1 Dodge Ram 1500(pickup) 2021 00-NONE ,i_ 12 _, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 I2 FIRE ❑ ® U2 C
c ®
TOLEDO OH 43609 0 1 0 KGF4985 OH 2025 IZFaR 0 N
D
OH D 1 C6SRFJT5MN581019 PROGRESSIVE ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 935873256 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 06 / F 2 8 0 1 0
##OCCS D
:A
/ / L.), 2 D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 09/11 12024 07 58 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
T
o 1 2 ❑ 2 28 / / ❑PM ❑Construction
Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
-a, ARREST NAME / / El PM '
o.2.
N 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
t 2 0 11 4 ARREST NAME AM
T / / pM El Unknown work zone type 45
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 45
1506-Nunez, Maria 502 - / / ❑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
Has a weight rating more than 10,000 pounds(example:truck or truck/trailer 1 �
c ` --I -' COr INDICATE NORTH comWrtatron)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ } i Not To Seale • - } ,. (example:shuttle or charter bus):or 0
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j4,1 I F„,,l,„"
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 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 ___j arp7ltmartlta I.
4. Is used or designated to transport between 9 and 15 passengers,including C
-- } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L L____a____. i i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires -u
r.0.i.
8 v95: :♦ g placarding(example:placards will be displayed on the vehicle). XI
wayi. / - —I
- CARRIER NAME Z
t7us ADDRESS D
MI Fhindill
N
Rd 0
r r T 1 1 Ill CITY/STATE/ZIP g
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
—— - TRAILER VIN 1 co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Red
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE