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HomeMy WebLinkAbout2024-00058340 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III HI IIIIIII II 11111111111111H11 101111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553953 u, 9 U2 1 1 1 U199 U2 1 U199 U2 U1 99 U2 1 1 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENEEl NOT ON • 7 VEHICLE/PROPERTY El OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00058340 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 E CHICAGO ST ❑Elgin RELATED ❑Y co" 09 12 2024 00:00 ®AM ❑YES ®NO U1 .( PRIVATE mo /day/yr El PM FLOW CONDITION m COUNTY PROPERTY ❑Y M N DOORING Y #OF MOTOR ❑SLOW 1 U) ❑ FT/MI N E S W Cook HIT&RUN ®Y ❑ N WITH ❑N VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 D4 ORNER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EOUES 0 NW 0 NCV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 .0. Unknown Unknown 00-NONE it 12 i' , DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 ,r 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 ® U2 1 m ion ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN 6 it ii 4 COM VI EH�� 0 ® ALGN OF CITY PLATE NO. STATE YEAR } 6 1 m F ID VIN INSURANCE CO. EXPIRED 1 -13 Unknown ❑Y 0 N U2 I— EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y r Same Unknown 1I— m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU X L ❑Y ® Same" 99 GI m 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) Fi20 4T TOWED Y N —I NAME(LAST,FIRST,M) mo day yr Nissan Rogue 2023 00-NONE tt` 12 1 DUE TO CRASH 0 ® 2 c 13-UNDER CARRIAGE 10 j I. 2 FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPCA C) a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value g Ut 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR )I I COM VEH 0 ® C FIRST CONTACT 1 7_.f a ._5 •ItYes,See Sidebar EK38681 IL 2024 1 O cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 7 5N1 BT3BA8PC917232 Allstate ❑" ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Composano.Gina.A. 81 1787395 BAC ' E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 452 N SPRING ST 1. ELGIN , IL.60120 (630)254-2126 Ut = (UNIT) (SEAT) /DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)r(ADDRESS)U;TELEPHONE I IEMSi (HOSPITAL) n I I - U2 996 r m / / - - '#OCCS D / /• U1 1 73 / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z N 1 ® 18 9 09/12 /2024 09 21 ❑pM in a Work Zone? ®N DIRP D 1 1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: Ut 7 C) T 2 0 99 99 ! / 0 PM ElConstruction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 3 Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME "'p N 8 AM 15 7 2 0 ARREST NAME 1 / pti1 ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 15 1530-Soto,Oscar 302 272-Bajak , / ❑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_ F 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 ?E7Chlcepo?8t 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I 1 0 INDICATE NORTH combination)or —I XI Not To Scale J BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. d i - - - -` ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i.----.....---% i -i } - i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_____A____: : i , — : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____--____; i . - i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' ADDRESS 0 N CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate unit ❑ Not in Comm./Govt. ElNot in Comm./Other Q DO ILCC NO m US DOT NO. d' m , XI Source of above Z . ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 Form Number 0 M X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE