HomeMy WebLinkAbout2024-00060393 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III HI
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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 •
2
0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00060393 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 1T
SUMMIT ST ® ❑
Elgin RELATED ❑Y CON 09 20 2024 04:09 ❑AM ❑YES ®NO U1 ,<
• PRIVATE mo l day I yr ®PM FLOW CONDITION m
I MI N E s ShadyOak
) PEDALCYCUST® [] FREE FLOW # LNS 0
ig DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRONT TOWED U, O
.Adrian 1 1 / 2 4 /1 9 9 8 Mitsubishi Lancer 2017 00-NONE „ 12 i' , DUE TO CRASH ❑ ® - E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 19•1 .r 2 FIRE 0 El <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 m
462 S ALFRED AVE M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF & IImj 4 •COM VEH 0 El 1 (7
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JA32V2FWOH0002139 PROGRESSIVE ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Same 943140765 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >
•'' RESPONDER Same VEHU
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0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PEE ❑PEDAL ❑EDUCE 0 WV ❑Rov 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi i DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 Xi
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c 13-UNDER CARRIAGE 10 I 11 2 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 n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value UI 0
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_1I a I_s CIO VEH
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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 RDEF73
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 <
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(UNIT) (SEAT) ;DOB) ISEXI (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) C)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ID U2 Z
N 1 ® 1 1 1 09/20 /2024 04 09 ®pm in a Work Zone? ®N DIRP co
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PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 3 C)
T 2 ❑ 11 1
! I 0 PM ❑Construction >t
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o U 1 ❑ CITATIONS ISSUES PENDING ROAD CLEARANCE TIME ❑Utility
o N 0 ❑ SECTION CITATION NO. AM 30
2 El ARREST NAME 09/20 /2024 04 09 ®PM 0 Unknown work zone type Ut
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? El1535-Solis. Laura 202 10 /22/2024 01 30 0 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 1 . 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 I ; ! i. ` ' ' '. ', ' l' ` 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 X1
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) 11
1.
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 0 >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? T
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 ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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