HomeMy WebLinkAbout2024-00061226 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi
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III II 11111111111 110110
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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 1
El NOT ON
VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2O24I2O24-00061226 VENT *
ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
WING ST ® ❑
Elgin RELATED ❑Y coN 09 24 2024 Ol:30 ❑AM ❑YES ®NO U1
PRIVATE mo /day I yr ®PM FLOW CONDITION m
5( I MI N E
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑MIN ❑Mcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 9 / 2 6 /2 0 0 4 FOR DAMAGEDAREA(S) FRONT TOWED U,
.Alexis, M. Nissan Murano 2014 00-NONE „ 12 , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ��) Y FIRE ❑ 21 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL (�I-TOTAL(ALL) DISTRACTED 0 1l U2 m
526 WESTGATE TER F ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,DistractlonValue 9 ALGN =
CITY PLATE NO. STATE YEAR POINT OF & {I 6 ii 4 COM VEH 0 El 4 0
JN8AZ1 MW4EW508186 Progressive ❑v ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn
Sanchez, Shelly 982152898 2 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
L 0 y°DEN 526 WESTGATE TER.Streamwood. I L.60107 (630)479-8488 VEHU
GI
m 0 DRNER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑KNEE 0 WV ❑Mcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 XI
C
Z 13-UNDER CARRIAGE 10 I 1 s 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 CI SPOR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value U1 0 -
POINT OF ICa
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_l1 6 I_5 VEH
0 C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPONDER
YOD NR Ut =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) C)
/ / U2
M
/ / - m
#OCCS y
/ / U1 1 m
/ I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ElY U2 Z
N 1 I:� 43 1 09/24 /2024 01 30 0 pm in a Work Zone? El N DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C)
T 2 ❑ 15 18
! , ❑PM El Construction *
cv 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / El PM SLMT
o U 1 CI CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N B AM 30
2 ❑ ARREST NAME , , ptil ❑Unknown work zone type Ut
N T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 El
410-DeLeon.Jessica 602 272-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.
0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
jIIIL -� } A CMV is defined as any motor vehicle used to transport passengers or property a, and.
( 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
novainiv4 combination)or
r } i i — -' ' INDICATE NORTH -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} i +, ', i — — -l' r r r (example.shuttle or charter bus)-or n
X
3 Is designed tocarry15 or fewer passengers and operated contractcar r
+ + 1 I I I ! } } transporting employees in the course of thir employment(exampleemployeerie
Ha w Stab } Y pbY
transporter-usually a van type vehicle or passenger car).or CO
0
i.____A____1 : i . ° B°° t i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, CTBIVCI
for direct compensation(example:large van used for specific purpose).or O
____-�____1 + - i } i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
ti placarding(example placards will be displayed on the vehicle) 71
>1 i. L CARRIER NAME Z
1 ` I
+ To
s ADDRESS En
•
\ \ • CITY/STATE/ZIP 0
\ \ 4410, - MOTOR CARR ID ❑ Interstate ❑ Intrastate
\ " ❑ Not in Comm./Govt. ElNot in Comm./Other OO
USDOT NO. ILCC NO.
C
, Source of above Z
. 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 2
ft. y
Blue
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage 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