HomeMy WebLinkAbout2024-00058007 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III IIIOII III I
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00058007 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
N STATE ST ® ❑
Elgin RELATED ®Y 0 N 09 11 2024 08'14 ®AM ❑YES ®NO U1
PRIVATE mo l day/yr El PM FLOW CONDITION m
FT/MI N E S W WING ST 'COUNTY PROPERTY El ®N DOORING 0 Y #OF MOTOR ❑SLOW CI)
El 'WITH VEHICLES INVLD ® STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS O
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRO TOWED U, 0
. Richard.J. 0 4 / 0 3 /1 9 7 1 M Chevrolet Equinox 2018 00-NONE 1112 , DUE TO CRASH p21
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE ( FIRE ❑ IN <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® 2' DISTRACTED ❑ Igl U2 m
1476 S PEMBROKE DR M SYSTEM IN ENGAGED 15-OTHER I]39 16-TOP 3 I
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
r CITY PLATE NO. STATE YEAR POINT OF 6 !1 6 II 4 COM VEH 0 ® 1 0
3G NAXJ EVXJS515146 Geico ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
a Same 6006607185 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L El ❑N 2 G1
m ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEOAL ❑ECUES 0 WV ❑Rov 0 ov U1
DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi , DUE TO CRASH 0 0
, NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 73
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c 13-UNDER CARRIAGE 10) 'I Y FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value Ut 0 -
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POINT OFto
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe53eeSidebarH ❑ ❑ C
1- REAR
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
D YOEl N Ut I
(UNITE (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) C)
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#OCCS >
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 1 09/1 1 /2024 08 14 ❑pM in a Work Zone? ®N DIRP co
T 2 0
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PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 5 0
a
! / 0 PM El Construction *
c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / El PM SLMT
o U 1 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N 8AM 3O
2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 ❑AM Workers present?
El225 Wolek.Thomas 272-Bajak i , p 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.
^ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
•
ADDITIONAL UNITS FORMS
' } A CMV is defined as any motor vehicle used to transport passengers or property and 1 . r r r r , , , , . r .
Z
1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` ; ; ', ', ; ! i. ` ' ' '. ', ' l' ` r r r (example.shuttle or charter bus)-or 0
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----i-----a a a I t • : - -, I I + i } - t transporting employees in the course of their employment(example.employee 71
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
r 9 Po P 9 N
for direct compensation(example.large van used for specific purpose).or O
i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) "0
1.
CARRIER NAME Z
' .. ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate El Intrastate <
❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
• , Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
Z
GVWR/GCWR —I
❑ <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles Z
own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown E
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash% p
❑ Yes No ❑ Unknown C
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
z
Form Number CJ
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? T
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
u 3 COLOR uCOLOR TRAILER LENGTH(S)1 ft 2 't Z
Blue
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO.TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE