HomeMy WebLinkAbout2024-00060244 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035651 6.
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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 2
0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00060244 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT
E CHICAGO ST ® ❑
Elgin RELATED ❑Y coN 09 20 2024 00:10 ®AM ❑YES ®NO U1 • ,<
PRIVATE mo l day I yr ❑PM FLOW CONDITION m
^,5 ®I MI N E O S W Liberty St 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR El SLOW CI)
I� 'WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS ' 0
110 DRIVER 0 PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑SIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
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NAME(LAST,FIRST,M) . Maykell,A. mo day yr Hyundai Sonata 2011 Do-NONE �� .i 72 , DUE TO CRASH El ❑ . E
,3-UNDERCARRIAGE 19 • 2 FIRE ❑ ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL (1�-TOTAL(ALL) O DISTRACTED 0 ® U2 m
408 E CH ICAGC ST 2 M ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 OTHER
99-UNKNOWN 9 76-TOP 3 .Distraction Value 9 ALGN • 2
CITY PLATE NO. STATE YEAR POINT OF & {I 6 ii 4 COM VEH 0 ® 1 O
a
5NPEB4AC5BH125940 UNKN El ❑N U2 43 . m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a Same UNKN 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 G1
m 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEOAL ❑EDUCE 0 WV ❑Rcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi i DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 73
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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 0 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 9
POINT OFto
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMes 3eeSideba❑ 0
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REAR
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS MID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER .I I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPONDER Y U, 2
(UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
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I I - #OCCS D
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I I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 3 ComEd Damaged light pole 09,20 ,2024 00 10 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ®AM U1 7
2 0 1700 SPENCER RD Joliet IL 60403 18 18 09 20 2024 00 12
/ / ❑PM ❑Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ®AM El Maintenance U2
a ARREST NAME 09/20/2024 00 34 ❑PM SLMT
o U 1 CITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Ulllity
o N SECTION CITATION NO. AM00
T
2 El ARREST NAME 09/20 /2024 04 21 ®PM ❑Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 0 ❑ 0 AM Workers present? ❑
1511 Ayala. Roberto 300 280-Marabillas / ❑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.
D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I i combination) or —I
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
J. J. d i -` ` r r r (example.shuttle or charter bus)-or n
pp X
Rio 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
0 } } transporting employeesmplooym nt(example employee
__ _.... � � � s s t in the course of their e e a M
r transporter-usually a van type vehicle or passenger car).or C
ewawuva
_ , / } r t 4 Is used or designated to transport between 9 and 15 passengers,including the driver, fn
for direct compensation(example.large van used for specific purpose).or O
L____-:_____; i , , -: i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
` placarding(example placards will be displayed on the vehicle) XI
I.
Nat g CARRIER NAME Z
' — .. ADDRESS 0
N
• CITY/STATE/ZIP 0
r ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r , USDOT NO. ILCC NO.
, Source of above Z
—I
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No PJ
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 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
CJ
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
BlackEn
U 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons 1 Impound Lot Garage 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