HomeMy WebLinkAbout2024-00059170 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 11111111111111H11 10111111111111 I
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553951
u, 1 U2 1 1 1 U1 5 U2 U, 1 U2 UI 1 U2 1 5 U, 1 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00059170 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 20 71
ALLEN DR El ID
❑Y CO" 09 15 2024 05:33 ❑AM ❑YES ®No u1 ,•<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W BRUCE DR 'COUNTY PROPERTY El ®" DOORING ❑y #OF MOTOR ❑SLOW U)
❑ Cook HIT&RUN ❑Y ® " WITH N VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 4 / 0 7 /1 9 6 7 FOR DAMAGEDAREA(S) FRONT TOWED U1
, Paul. R. Harley Davids&uper Glide 2002 00-NONE it. 12 , DUE TO CRASH ® ❑ - E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 I z FIRE ❑ ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
996 BRUCE DR M ❑Y IN NSYSTEM❑UNK VEH. O ATCRASH D O 99-UUTHER NKNOWN 9 16-TOP® Distraction Value 9 ALGN =
r POINT OF 8 1 O •COM VEH 0 ISI C)CITY PLATE NO. STATE YEAR 6 1
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1 H D1 FBW192Y643173 Allstate ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
a Same 802122280 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
>. RESPONDER Same VEHU
L ❑Y ®" 2 G1
' ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 NOV ❑NCV 0 ON DATE OF BIRTH MAKE MODEL YEAR U1
CIRCLE NUMBER(S) Y N m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 73
C
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 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value UI 0 -
POINT OF
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 6 I_S CIOMe63eeSideba❑ ❑ C
to
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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 995 <
D YO0NR Ut I
(UNITE (SEAT) ;GOB) (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
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/ / - m
#OCCS y
/ / U1 1 73
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z
u ® 2 1 09/15 /2024 05 33 ®pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5
s 2 ❑ 20 05 09/15 /2024 05 33 ®PM El Construction *
N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
ARREST NAME Kasman, Paul. R. 11-501-A-2 751573 09/15/2024 05 42 ®PM SLMT
o u 1 0 CITATIONS ISSUED SECTION CITATION NO.
PENDING ROAD CLEARANCE TIME 0 Utility
o N AM 20
2 ❑ ARREST NAME 09/15 /2024 07 15 El RA0 Unknown work zone type Ut
T • OFFICER ID SIGNATURE BEAT/DIST. •
SUPERVISOR ID. COURT DATE TIME Y
2 3 El1526-Walsh.Jacob 302 246-Kite 10 ,21 /2024 09 00 0 pM wDrkerspresenn ®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
' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z
0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer -<
' r i ; i i i- r r , , i r INDICATE NORTH combination) or —I
M
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', ! ' ' 1 ', ' I. ` r r r (example'.shuttle or charter bus)-or
X
; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or w
' r i• 4 Is used or designated to transport between 9 and 15 passengers,including the driver,
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) 11
•
CARRIER NAME Z
' ADDRESS 0
N
. n
•
• CITY/STATE/ZIP 0
. - MOTOR CARR ID ❑ Interstate El Intrastate
•
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r ,-•---, r - DO ILCC NO. m
U N XI
, Source of above Z
_ own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ 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 ❑ -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
Form Number 0
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft Z
Blackip
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE