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HomeMy WebLinkAbout2024-00060816 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III I IIIIIII II 11111111111 111111101111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003566406 u, 1 U2 13 4 2 Ui 4 U2 U, 1 U2 Ut 1 U2 1 6 U1 15 U2 *P 0119* 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 • 3 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2O24I2024-00060816 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 BIG TIMBER RD ® ❑ Elgin RELATED ❑Y CON 09 22 2024 02:53 DAM ❑YES ®No u1 • ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m ® �/ 1 COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW VEHICLES INVLD El STOPPED U2 01 MI O E S W Florimond Dr -I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN WITH PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NIN 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n .TOMMY. L. 12 / 21 J 1 9 9 1 Ford Focus FOR DAMAGEDAREA(S) FRONT TOWED U, 2013 00-NONE 11 12 i' , DUE TO CRASH El ❑ E NAME(LAST,FIRST,M) mo day yr © UNDER CARRIAGE i0 2 FIRE ❑ IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 1681 COLLEGE GREEN DR M SYSTM❑Y IN NEDUNK VEH. O ATCRASH D 0 99-UUNKNOWN THER9 76-TOP 3 Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR FIRSNT T COONTACT 13 y 11 a f!5 COM VEH 0 El 1 O "If Yes,See Sidebar U1 Z 1FADP3K2XDL344989 NIA ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn a 99 9 Same NIA 2 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU L ❑Y ®N 2 G1 ' ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Rov 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m a / / FOR DAMAGED AREA(S) FRONT TOWED fi DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C a 13-UNDER CARRIAGE 101 I' s FIRE ❑ 0 U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 SPDR n a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X ❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II 61_S COM e53eeSideba❑ 0 C H R • C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2CA 0 ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 2 BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < RESPDY 0NR Ut 2 (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n / / U2 r M / / - #OCCS D / / U1 1 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z 1 N 1 ® 1 3 City of Elgin Traffic sign post 09/22 ,2024 02 53 ®pm in a Work Zone? ®N DIRP co PROPERTY OWNERS ADDRESS:STREET,CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: U1 3 C) T 2 0 34 3 150 DEXTER CT ELGIN IL 60120 11 10 ❑AM ! / PM El Construction * t c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 ARREST NAME LEMON.TOMMY. L. 3-707 51509000127 / / ❑PM SLMT o U 1 0 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility a N II AM 45 2 0 ARREST NAME 1 / ptil Ut ❑Unknown work zone type ¢ T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ 0 AM Workers present? ElY 1509 Wortman.Cassie 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. _ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r (Ts. yx I' I _� } A CMV is defined as any motor vehicle used to transport passengers or property and. Z ' y 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer , r 1 i ; (Tom combination) or INDICATE NORTHXI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver ', -! ` r r r (example'.shuttle or charter bus)-or ---- ----� ® J - i transporting employeeslin the course of theiremployment(example�emaployeerier 0 3 f transporter-usually a van type vehicle or passenger car).or w :____A____: : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C I ) f \ t for direct compensation(example:large van used for specific purpose).or O _____L____; 1 I y : 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m r placarding(example placards will be isplayed on the vehicle) 71 I I CARRIER NAME Z ' � t ADDRESS '� '' O I En r CITY/STATE/ZIP !r I MOTOR CARR ID ❑ Interstate ❑ Intrastate . . / I ) 0 Not in Comm./Govt. Not in Comm./Other J f USDOT NO. ILCC NO. m , 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 M 7) 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? O ❑ 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 0 m 7a 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO- Other SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE