HomeMy WebLinkAbout2024-00060310 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
10110110011001111 I0�1001111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463562861
u, 9 u21 1 1 1 U1 9 U2 1 U,99 U2 1 U1 99 U2 99 1 18 U,23 U2 1 *P 0119�K
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 0 ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2024I 2024-0006031 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED 0 Y ®N 09 20 2024 ®AM El YES ®NO U1
20 TYLER CREEK PL Elgin PRIVATE mo /day/yr 09:00 ❑PM FLOW CONDITION m
®10�F !MI N O s w North McLean Blvd COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 3 Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 4 /
yr 13-UNDER CARRIAGE 101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
M 9 9 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s l 6 1, COM VEH 0 is! 1 C)
~ ELGIN IL 60123 0 9 FIRST CONTACT 7 tz_;1 __5 *II Yes.See Sidebar U1 0
Z CF52786 I L ' E
TELEPHONE
IL D 0 2C4RDGBG9ER161670 State Farm ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0599711SFP13 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER 0 0
N DRIVER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑Nuy 0 i v ❑DV
1 9 5 0 Dodge Caravan(inc Grand)2019 00-NONE 1t-1 12..-_, DUETO CRASH 0 C 2
o yr 13-UNDERCARRIAGE 10;i c• . 2 FIRE ❑ ® U2 C
P.
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 6 4 COM VEH D ® Ut CO
FIRST CONTACT 3 Y��l _5 •(ryes,See Sidebar C
H E LG I N I L 60123 0 1 D244158 I L 2025 REAR 0 N
M
IL D 0 2C4RDGCG2KR679422 Teachers Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 65000016330109 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 09,20 (2024 10 50 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 18
N 1 3 0 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM, ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a ARREST NAME / / ❑PM '
o, N 1 ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
10
r 2 0 ARREST NAME AM
7 ( r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 10
547 Homeier.William 272-Bajak / ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
• i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue 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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE