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HomeMy WebLinkAbout2024-00061332 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III Ifi III ll II I LY 11111111111 1101101111110111111Ir��.} DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35651 u, 1 U2 1 1 1 Ui 1 U2 U, 1 U2 Ut 1 U2 5 4 Ut 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENEEI NOT ON 2 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDED (DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061332 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 HIGGINS RD ® ❑ Elgin RELATED ❑Y coN 09 25 2024 05:32 ®AM ❑YES ®NO U1 PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING #OF MOTOR ❑SLOW CI) (� ®I MI N E S© Wesemann ) Kane HIT&RUN ❑Y ® N ❑y PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NMI 0 NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) FRONT TOWED Ut O NAME(LAST,FIRST,M) . L. 0 mo day / a 11 '1 9 6 6 Ford Escape 2015 00-NONE ti All' , DUE To CRASH El ,3-UNDERCARRIAGE to 2l I FIRE E SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m 6288 IL ROUTE 38 7 M SYSTEM IN ENGAGED t5-OTHER 9 76-TOP 3 _ PLATE NO. STATE YEAR POINT OF e l COM VEH 0 0 1 0 ~ 1 FMCUOG75FUB26100 State Farm ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn e Same K470613F2813 2 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER 3 Same VEHU 0 DRIVER ❑ PARKED 0 CRNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut 2 • m a / / FOR DAMAGED AREA(S) FRONT TOWED fit DUE TO CRASH 0 0 , NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C c 13-UNDER CARRIAGE 19) I 2 FIRE ❑ ❑ U2 C i STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 - POINT OFCa N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II a I_5 C•IOMe63eeSideba❑ 0 C 1— r TEAR M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑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 U, 2 (UNIT) (SEAT) (DOB) (SEX) )SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) C) / / U2 r M • / / - '#OcCS ' > / / U1 1 D / I 0 EV MOST EVNT• LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 15 1 Department of Natural Resources Deer 91 /51 /024 05 32 ❑PM 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 3 2 0 1 NATURAL RESOURCES WA ' rin fieldl 62702 99 99 P 9 / , 0 PM ❑Construction N 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2 Q ARREST NAME / / ❑PM SLMT o U 1 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N 8 AM 45 � T 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 --0 0 AM Workers present? ❑ 298-Lopez. Mirko 901 272-Bajak r , p 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 ' r A CMV is defined as any motor vehicle used to transport passengers or property and. Z : l : l : 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ I ', ! i. ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------t-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP O • . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other Q C r-----.-----, r r r r ,-•---, i '- DO ILCC NO. m U N XI , Source of above Z . ❑ 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 RedEn - U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO 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