HomeMy WebLinkAbout2024-00061705 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
u, 1 U2 3 4 1 U, 1 U2 U, 1 U2 UI 1 U2 1 11 U1 11 U2 *P 0119*
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 S
VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2O24I2O24-00061705 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '�'1
DUNDEE AVE ❑Elgin RELATED ❑Y CON 09 26 2024 04_28 El—DATE
®NO U1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
Fri MI N E S W STEWART
) PEDALCYCUST El ® FREE FLOW # LNS 0
DI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIA/ ❑Rey 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 8 / 3 0 /2 0 0 2 FOR DAMAGEDAREA(S) FRONT TOWED Ut
NAME(LAST,FIRST,M) p mo day yr
,Guadalupe Chevrolet Equinox 2019 00-NONE „ 12 i' , DUE TO CRASH p 21
,3-UNDER CARRIAGE �0 I 2 FIRE 0 IA <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m
636 OAKLAND AVE F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF & II®j�� 4 COMVEH 0 ❑ 1 O
2GNAXHEV5K6162145 State Farm ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Stevens.Amelia 2292052-SFP-13 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
L 0 Y J N 636 OAKWOOD BLVD. ELGIN . IL.60120 (224)800-8609 VEHU
m 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 NW ❑Nov 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 73
C
"I', 13-UNDER CARRIAGE 10 i .I 3 FIRE ❑ 0 U2 C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPOR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value U1 0 -
POINT OFto
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_1I a I_S C•IOMe63eeSidebarH ❑ ❑ C
1- WAR
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 <
DYO0NR U, _
(UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) {INJI (EJCTI (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 ❑Y U2 Z
N 1 ® 11 1 9/ /6/ /024 04 28 ®pm in a Work Zone? ElN DIRP co
T 2 0
I
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 1 C)
a
! / 0 PM El Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
a ARREST NAME / / ElPM SLMT
o U 1 ❑ • 0 Utility
0 CITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8AM 35
2 0 ARREST NAME , / ptil ❑Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 El ®AM Workers present? El Y
475-Willians. Brianna 201 334-Fries 11 , 12,2024 09 00 0 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.
r 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. Z
r- -r--- 4 , 4 r r r r r , , , 1 . r
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' 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- ._ ' ' '. ', ' 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------.-----• + + • : - -, 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 03
' r i• 4 Is used or designated to transport between 9 and 15 passengers,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
. `
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP O
, ,
MOTOR CARR ID ❑ Interstate ElIntrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r r•---, i - DO ILCC NO. m
U N XI
, Source of above Z
_ GVVVR/GCWR
❑ <10,000 0 10,000-26,000 0 >26,000 Z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard 0
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 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 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Gray
-
U 3 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