HomeMy WebLinkAbout2024-00061940 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III III III )III
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 13
0 NOT ON
VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061940 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1
INVERNESS DR El ❑ EH,'"RELATED ❑Y co" 09 27 2024 03:55 ❑ ❑YES ®NO U1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ®SLOW CI)
❑ FT/MI N E S W Cook 0 Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION W HIT&RUN WITH (NAME OF ) PEDALCYCUST El ❑ FREE FLOW # LNS 0
❑DRIVER Cg PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
/ / FOR DAMAGEDAREA(S) FRONT_ TOWED U, O
Lincoln MKX 2013 00-NONE 11 12 1 DUE TO CRASH ❑ 21 E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 I 2 FIRE 0 1 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m
SYSTEM IN ENGAGEDOTHER 9 16-TOP 3
❑Y ®N DUNK VEH. O AT CRASH 0 9 -UNKNOWN 'Distraction Value 9 ALGN ..
r CITY PLATE NO. STATE YEAR POINT OF s I®j( 4 COMVEH 0 El 1 O
F FIRST CONTACT 6 OT_.. 1.OS "If Yes,See Sidebar U1 0
Z CV82572 IL 2024 REAR
. ID VIN INSURANCE CO. EXPIRED
2LMDJ8JK9DBL23853 None ❑Y ❑N U2 m
m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a r 99 9 Zapata-Ana None 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER N 275 BROOK ST A. ELG I N - IL.60120 (224)318-5020 VEHU 6)
m 0 DRIVER 0 PARKED 0 DRNERLESS ❑ PED ❑PEOAL ❑EQUES 0 WV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi 1 DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 73
C
c 13-UNDER CARRIAGE 10 I I 2 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 0 SPOR C)
Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN II4 •DistractionValue U1 0 -
❑
POINT OFCa
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II a l-5 C•IO M VEH
See Sidebar
0 C
1— REAR
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 Ut =
(UNIT( (SEAT) ;GOB) ISEXI (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) {EMS) (HOSPITAL) C)
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I I - '#OGCS >
/ / U1 D
I I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME 0 AM Did crash occur 0 Y U2 Z
N 1 ® 1 1 5 09/27 /2024 03 55 ®PM in a Work Zone? El DIRP D
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 5 0
a
T 2 ❑
! 1 0 PM El Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o U 1 ❑ 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
2 N 10
8 AMPM ❑Unknown work zone type U1
2 0 ARREST NAME r /
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ElY
485-Quintana.Josue 302 334-Fries ( / ❑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 1 . r r r r , , , , . r .
Z
1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` ; ; I I ; ! i. ` ' ' '. ', ' l' ` r r r (example.shuttle or charter bus)-or 0
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----i-----a a a I t • : - -, I I + i } - t transporting employees in the course of their employment(example.employee X1
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
r 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
1.
CARRIER NAME Z
' .. ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate El Intrastate <
❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
• , Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
Z
GVWR/GCWR —I
❑ <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 X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles Z
own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown E
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash% p
❑ 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 CJ
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? T
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
u 3 COLOR uCOLOR TRAILER LENGTH(S)1 ft 2 't 2
Black
U 3 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