HomeMy WebLinkAbout2024-00060013 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III )III
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
ut U2 2 4 1 U1 U2 U1 U2 U1 U2 1 10 U1 U2 *P0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00060013 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 'IT
SHALES PKWY El El
®Y ❑N 09 19 2024 07:42 ®AM ❑YES ®NO U1 .(
PRIVATE mo l day I yr El PM FLOW CONDITION m
FT/MI N E S W MAROON DR COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW CI)
❑ Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
❑ORNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGED AREA(S) FRONT_ TOWED U1 0
00-NONE 11 12 1 DUE TO CRASH ❑ ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 I 2 FIRE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ❑ ❑
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 16-TOP 3
r ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN
& {I 4 Distraction
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CITY PLATE NO. STATE YEARn
FIRST CONTACT 7__.{{ 6 COM ER 0 0 REAR
5 "If Yes,See Sidebar U1 0
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p . ID VIN INSURANCE CO. EXPIRED
o ❑Y ❑N U2 m RSUR m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER m
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o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
>. RESPONDER VEHU D
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❑DRNER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUM ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / 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
a 13-UNDER CARRIAGE 10 I 11 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ❑ SPDR 0
A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1
POINT OFto
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe6VSeeSideba❑ o C
1- REAR C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
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❑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 C
D YOEl N Ut I
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ElY U2 Z
N 1 - El - 91 /91 /024 07 42 ❑pM in a Work Zone? ®N DIRP co
1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ®AM
It YES check one below: U1 0
iii? T 2 ❑ 91 ,91 ,024 07 44 I]PM ElConstruction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ®AM El Maintenance U2
ARREST NAME 91 l 91 /024 07 48 ❑PM SLMT
o u 1 CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility
,- N SECTION CITATION NO. AM
1 2 ❑ ARREST NAME 91 ,91 /024 08 32 El RA0 Unknown work zone type U1
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2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
319-Ross..Adam 302 275-Engelke 11 , 12/2024 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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
' r A CMV is defined as any motor vehicle used to transport passengers or property and. Z
: l : l : 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' •_ I ', ! i. ._ ' ' '. ', ' f ` 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------t-----• + + • : - -, 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 03
' 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
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placarding(example placards will be displayed on the vehicle) .Z1
X.
. `
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP n
• . • - MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not in Comm./Govt. El Not in Comm./Other Q
C
r-----.-----, r r r r ,-•---, i - DO ILCC NO. m
U N XI
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, Source of above Z
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.
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No P3
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 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
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
• - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
UTOWED ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO
DUE 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