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HomeMy WebLinkAbout2024-00059210 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III HI IIIIIII II 111111llIllIllHllfll llfllfllflhlU I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555520- u, 9 U2 1 1 1 Ui 4 U2 1 u1 99 uz 99 u, 99 U2 1 9 9 Ut 1 U221 *P 0119* 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 • 3 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2O24-0005921 O VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 S EDISON ST El ❑ Elgin RELATED ❑Y co" 09 15 2024 09'36 DAM ❑YES ®No u1 '< PRIVATE mo /day/yr ®PM FLOW CONDITION m q0 ® 'COUNTY PROPERTY El M N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) IIXX1l3_ /MI N E S W South St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NW ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) .0. mo day yr Unknown Unknown 00-NONE 11 12 /1 DUE TO CRASH ❑ 21 ,3-UNDERCARRIAGE lJ FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 Il U2 1 n<I SYSTEM IN ENGAGED 15-OTHER 916-TOPO3 = M ❑Y ❑N ®UNK VEH. 9 AT CRASH 9 99-UNKNOWN 'Distraction Value g ALGN .- r ' POINT OF 8 l O COM VEH 0 CITY PLATE NO. STATE YEAR i4 61 O w F Unknown ❑Y ❑N U2 m I— M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU .5 ❑Y ® Same" 99 0 0 DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Chevrolet Malibu 2003 00-NONE 1' 12 y DUE TO CRASH ❑ 21 1XI c 13-UNDERCARRIAGE of I: Y FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED0 a SYSTEM IN 0 ENGAGED O 15-OTHER O9 16-TOP 3 0 El SPDR X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN ©, •4 •Distraction Value g U, 0 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1II I� COM VEH 0 ® C F FIRST CONTACT 8 7_.1 a ._S •byes,See Sidebar DR16943 IL 2025 REAR O cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2G1WF52E139434316 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Hayes. Harry. L. 27542026 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 993 SOUTH ST. ELGIN . IL.60123 (630)258-4163 U1 = (UNIT( (SEAT) ;DOB) ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/-f ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n / I - U2 996 r m / / - #OCCS y / /• U1 1 m Ito / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 1 09/15 /2024 09 36 ®pm in a Work Zone? ®N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C) T 2 0 28 04 ! I 0 PM ❑Construction * t N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME El AM El Maintenance U2 1 Q ® 11 1 ARREST NAME / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility o N ❑ ❑ SECTION CITATION NO. AM 35 2 0 ARREST NAME 09/15 /2024 09 36 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 1513-Mann. Nathaniel 701 280-Marabillas / / El PM Workers Am present? ®N U2 35 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I ADDITIONAL UNITS FORMS _ } A CMV is defined as any motor vehicle used to transport passengers or property and.r r_.. • , 0 Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer , r 1 . ; ; I combination) or —I INDICATE NORTH71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', ', i I -` ` r r r (example'.shuttle or charter bus)-or r7 i_-----;-----% I t } t transporting employeeslin the courseaof theiremployment(example�emaployeerier O�3. I s } trans transporter-usually a van type vehicle or passenger car).or w i_____A____: : , t I : i r i 4 Is used or designated to transport between9and 15passengers,including the driver, N / l for direct compensation(example:large van used for specific purpose).or O L_____L____; ; ; , S@Iurf— —at — i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires -13rn placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ADDRESS 0 CITY/STATE/ZIP a. MOTOR CARR ID ❑ Interstate ❑ Intrastate r , 0 Not in Comm./Govt. ElNot in Comm./Other Q r- -'-- i i r r USDOT NO. ILCC NO. Not To Scale 1 xi m , Source of above Z . 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 D m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE