HomeMy WebLinkAbout2024-00058495 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII 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 0 A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW 1
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
D NOT ON S
VEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00058495 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S RANDALL RD ® ❑
Elgin RELATED ❑Y CON 09 12 2024 08:43 ❑AM ❑YES ®No U1 .•<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
ON 'COUNTY PROPERTY ❑Y ®N 1 DOORING ❑Y #OF MOTOR ❑SLOW CI)
/MI N E Ci W South St 'WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS ' 0
ig DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Rey 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 6 / 2 6 /1 9 4 8 FOR DAMAGED AREA(S) FRONT TOWED U, ()
.A. Toyota Camry 2024 00-NONE 11 , 1 DUE TO CRASH 171 ❑
NAME(LAST,FIRST,M) mo day yr 12
,3-UNDERCARRIAGE 10) 2 FIRE ❑ El E
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IgI U2 m
234 RODEO DR M ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value 9 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 6 {Imj�i 4 COMVEH 0 El 1 0
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4T1 F31 AKXRU626504 State Farm ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Same 2454754-SFP-13 1
r Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
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❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEOPL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH ❑ El
NAME(LAST,FIRST,M) mo day yr 00-NONE 11_ 12 73
c 13-UNDER CARRIAGE 10 I 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 SPOR C)❑Y CI N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 -
POINT OF
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 VEH
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C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPEl ONR U, 2
(UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
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M
/ / - #OCCS D
/ / U1 1 D
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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 ® 11 1 91 /21 /024 08 43 ®pM in a Work Zone? ®N DIRP co
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED T)MF ❑AM It YES check one below: U1 5 C)
T 2 ❑ 91 /21 /024 08 43 ®PM ❑Construction *
or 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM ❑Maintenance U2
Q ARREST NAME 91 /21 /024 08 51 Ili PM SLMT
o U 1 ❑ 0 CITATIONS ISSUES PENDING ROAD CLEARANCE TIME . 0 Utility
SECTION CITATION NO.
o N AM 50
% T
2 El ARREST NAME 91 /21 /024 09 15 El pm0 Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ ®AM Workers present? El Am
388-N elis. Ryan 801 10 / 81 /024 09 00 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, . 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. ` ' ' 1 ', ' I. ` 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) M
•
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 1=1 >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? m
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
u 3 COLOR uCOLOR TRAILER LENGTH(S)1 ft 2 't
vi
Silver
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑zr DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY!1
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE