HomeMy WebLinkAbout2024-00061044 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III 11 IM UHI UU lOft11 I UU�IIIUUIOODU
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00061044 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 mN STATE ST El In03:07
® ❑ RELATED ❑Y ®N 09 23 2024 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
10 !MI N E S W North Tollgate Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
® 0 g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGED AREA(S) TOWED U1 Q
NAME(LAST,FIRST,M) Jones. Ralph.A. 1 2
yr iS-UNDER CARRIAGE I� FIRE 0
IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 4 <<Tl
M 2 SYSTM IN ENGAGETHER
4 ❑Y El NE DUNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 016-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail 6 �'.4 COM VEH 0 El 1 0
~ South Elgin IL 60177 0 1 0 FIRST CONTACT 9 7_:1 -_S *If Yes.See&debar Ut
Z 9 3301086 IN 2025 REAR
TELEPHONE
IL D 7 1 FUJHHDRORLUX8671 Liberty Mutal Insurance ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Transport America 016067969 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 en
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m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0
yr 12
0 13-UNDER CARRIAGE 101• 61
FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistracti n value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 6 �.- 4 C.OM VEH D ® Ut CO
FIRST CONTACT 3 Y—�_,-`-�•(ryes,See Sidebar C
ELGIN IL 60123 0 1 0 BQ88156 IL 2024 REAR Si)0
IL D 0 1 G 1 ZD5ST4J F123081 Country Financial ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same PO10224758 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 09(23 (2024 03 07 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 0 20 99 1 ( 0 PM ❑Construction *
1
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Jones. Ralph.A. 11-905 W1500000276 / ( El PM
1 ® 1 1 1 ❑CITATIONS ISSUED PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y
0 AM
t 2 0 ARREST NAME 09/23 (2024 04 00 0 PM 0 Unknown work zone type U1 45
n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 45
1500-Chew. Marie 501 334-Fries / ❑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
?Rd ADDITIONAL UNITS FORMS.
r r----T----, , ; 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 INDICATE NORTH combination):or —I
-1r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
5
,
_ r r (example:shuttle or charter bus):or
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
, r0-- 1 I t - . . 1- transporting employees In the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or c0
I _ 4. Is used or designated to transport between 9 and 15C
0 I Not To � } } } for direct compensation(example:large van used for passengers,cific purpose):including the driver, to
Nil I Pe ( P 9 Pe or O
_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i placarding(example:placards will be displayed on the vehicle). ;p
1 Unit 1 D
ICARRIER NAME Z
ADDRESS 0
I
MD CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
I I T I I ` ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
r-----r--- C 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Blue
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE