HomeMy WebLinkAbout2024-00062173 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III III III I
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 ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®$501-$1,500 ❑ON SCENE 15
[21 NOT ON
VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2O24I2O24-00062173 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH '11
N MCLEAN BLVD ❑Elgin RELATED ®Y ❑N 09 28 2024 04:48 ❑AM ❑YES ®NO U1 .(
PRIVATE mo l day I yr ®PM FLOW CONDITION m
FT/MI N E S W M I LD R E D
) Kane HIT&RUN El CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0
❑DRNER ❑ PARKED ❑ERNERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGED AREA(S) FRONT_ TOWED U1 0
00-NONE 11 12 1 DUE TO CRASH El El
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE ❑ ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 16-TOP 3
r ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN
6 {I� 4 COM VIEH ion�� ALGN
OF
CITY PLATE NO. STATE YEAR it 6 ❑ 0 n
FIRST CONTACT 7__.REAR
-, 5 'If Yes,See Sidebar U1 0
ID VIN INSURANCE CO. EXPIRED
o ❑Y D N U2 m RSUR m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER m
1 I—
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER VEHU D
o ❑Y ❑N G')
m ❑DRNER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
c 13-UNDER CARRIAGE 101 I. p FIRE ❑ ❑ U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPUR 0
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1
POINT OFCO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_ll 6 I_5 C•IOMe63eeSideba❑ 0 C
1— r
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 C
RESPONDER
YO0NR Ut =
(UNIT( (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) {EMS) (HOSPITAL) C)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
N 1 El 09/28 /2024 04 30 ®PM in a Work Zone? ®N DIRP CO
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 0 T 2 ❑
t
! , PM El Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
ARREST NAME / / ❑PM SLMT
o U 1 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
o N 8 AM
2 0 ARREST NAME ) , ptil ❑Unknown work zone type U1
Fo T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ CI Am Workers present? ElY
558-Lara. _izette 501 246-Kite ) , ❑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
1 Has a weight rating m0 ore than 10,000 pounds(example.truck or truckrtrailer -<
r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I ' t ` ` ` ' ' '. ' ' ` ` 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
X.
. `
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r ,-•---, r '- 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
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
• - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
UTOWED ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO
DUE 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