HomeMy WebLinkAbout2024-00061878 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II 11111111111 11011 111111111111111101
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003565049*
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE •
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El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061878 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m583 N MCLEAN BLVD ® ❑
Elgin RELATED ❑Y co" 09 27 2024 10:56 ®AM ❑YES ®No u1 ,-‹
PRIVATE mo /day/yr ❑PM FLOW CONDITION m
0 N 'COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ❑SLOW CI)
col ICJ/MI OE s w Eagle Rd WITH VEHICLES INVLD ElSTOPPED U2 —1
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IM N PEDALCYCUST®N ® FREE FLOW # LNS ' O
tg DRIVER 0 PARKED 0 DRIVERLESS 0 PEo ❑PEDAL ❑EOUES 0 Nmi ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
FOR DAMAGEDAREA(S) FRONT TOWED U1
. P. 0 9 / 1 1 J 1 9 6 3 International Gffa6 s1fg 2024 00-NONE 11 12 i' 1 DUETOCRASH ❑ 21
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10) .• r 2 FIRE 0 IA <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
1523 EUCLID AVE M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UNKNOWN THER 9 16-TOP 3 Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF & {I®j 4 COMVEH 0 El 1 O
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in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a DO LOGISTICS LLC ISAH1069050A 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r
o RESPONDER
Y DEN 100 MISSION RDG .GOODLETTSVILLE.TN ,37072 (615)399-4265 VEHU 0
5' ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 NOV ❑NCv 0 Dv CIRCLE NUMBER(S) U1
DATE OF BIRTH MAKE MODEL YEAR 98 m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi1 DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 71
c 13-UNDER CARRIAGE 10 j I 2 FIRE ❑ ❑ 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 0 SPDR C)❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 -
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_Il a I_5 CIOMe63eeSideba❑ 0
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RESPONDER
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(UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 5 COMED DAMAGED COMED WIRE 09,27 /2024 10 56 0pM ina 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 ❑AMU1 1
2 ❑ 10 S DEARBORN ST Chicago IL 60603 30 99
g ! , 0 PM ❑Construction *
N 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 0 0 Utility
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
NB AM 99
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2 0 ARREST NAME 1 / pti1 ❑Unknown work zone type Ut
• OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ ❑AM Workers present? ❑
244-Blomberg. Michael 601 272-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.
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
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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
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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
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3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------i-----• + + • : - -, 1 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 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
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placarding(example placards will be displayed on the vehicle) .Z1
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. `
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP n
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• . - MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
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Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No P3
73
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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
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X1
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 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
WhiteEn
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U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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