Loading...
HomeMy WebLinkAbout2024-00059586 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi IIIIIII II 11111111IllIllHl 101 11111 11111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555536a u, 1 U2 1 1 1 1 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 1 12 U123 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 1 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059586 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 'IT S LIBERTY ST ® ❑ Elgin RELATED ❑Y coN 09 17 2024 01:45 ❑AM ❑YES ®No u1 ,-< PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ElSLOW 1 N ®,MI N E OS w MAY St WITH VEHICLES INVLD El STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O DA ORNER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 mo day yr 12 - 13-UNDERCARRIAGE 191• 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 2 m 217 PEARL ST M SYTM THER ❑Y ®S NE❑UNK VEH. O AT CRASH 0D 99-UNK 15- NOWN 9 16-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 {Imji 4 COMVEH 0 ® 1 0 I— FIRST CONTACT 6 7__,{REnR 5 'If Yes,See Sidebar U1 Z 1 JJV281 D6SL536301 Louisiana Auto ®v ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Saia Motor Freight L 016052736 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > o RESPONDER 104 E WOODLAWN RANCH RD. Houma. LA.70363 (847)680-5035 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 98 m m / / FOR DAMAGED AREA(S) FRONT TOWED CRasH Y N s Lan Eric 1 1 2 71 9 9 8 Nissan Sentra 2019 00-NONE 1t' 1' , ❑ ® 2 —I , NAME(LAST,FIRST,M) g• mo day yr 10 ©II 2 FIRE ❑ MI U2 XI v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) E 108 GRANVILLE AVE M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® ❑N UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7_1-6-7 .5 ClfvesVSeeSidebar❑ ® U1to C BELLWOOD IL 60104 0 DT45575 IL 2024 O f/j, D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)456-6410 L520-2009-8337 IL D 0 3N1AB7AP7KY213929 Insure the Spot ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same ILT5965644 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Same Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME),(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - #OCCS y / /• U1 1 m 11* I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 09/17 /2024 01 45 0 pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T 2 0 30 28 / , 0 PM ❑Construction * 1 N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM ❑Maintenance U2 5 Q CO 11 1 ARREST NAME / / ❑PM SLMT O UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' ❑Utility o N 0 ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 09/17 /2024 02 50 ®PM 0 Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? El Y 30 1507 Ruiz.Alondra 401 334-Fries , p PM ElN 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. r 0IF 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 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or —I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` 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------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 desi nated to trans rt between 9 and 15 assen ers 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 • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, - DO ILCC NO. m U N XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 73 m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 0 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 White WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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