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HomeMy WebLinkAbout2024-00062611 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III II 0 lu II 1111111111111111111111111110 � II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035:2238 u1 1 U2 1 1 1 U1 1 U2 Ut 1 U2 U1 99 U2 4 4 Ut 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash yR 20241 2 024-0 0 0 62611 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 71 S STATE ST ® ❑ Elgin RELATED ❑Y coN 09 30 2024 07:06 DAM ❑YES ®NO U1 ,< PRIVATE mo l day I yr ®PM FLOW CONDITION m 1 0 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR CI SLOW CI) ® �i/MI N E O W Middle Rd 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES ❑NW ❑NcV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) RlaNT TOWED U1 0 3 / 1 2 /1 9 7 3 Dodge Durango 2012 00-NONE 0' ..©.,0 DUE TO CRASH El vi NAME(LAST,FIRST,M) mo day yr 13-UNDERCARRIAGE 1pi 2 FIRE < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ISI 0 U2 m 569 DEAN DR 4 M ❑Y El NE DUNK VEH. 0 SYSTM AT CRASH 99-UUNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = THER r CITY PLATE NO. STATE YEAR POINT •OF 8 . 4 COM VEH ❑ ® 2 0 FIRST CONTACT 12 7_.; 6-:__6 ^YYes,See Sidebar U1 Z 1 C4 R DJAG 9CC15241 0 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same J7742900O213C 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU 73 L ❑Y ®N 2 0 ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m a / / FOR DAMAGED AREA(S) FRONT TOWED fi DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 1Y 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 0 0 SPDR n a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 4 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_Il 6 I. CIO VEH ❑ C to H p • C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF73 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 < 0 YO0NR Ut I (UNIT) I SEAT) (DOB) I SEX, ;SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n 1 6 02 /1 1 /2009 M 2 4 0 1 0 Dante X. Serna/569 DEAN DR 1.SOUTH ELGIN,IL,60177 Refused r (847)660-0055 U2 m / / #OCCS D / / u1 2 m / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 15 1 Illinois Department of Natural Resources Deer 91 ,01 ,024 07 07 ®AM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP 0 AM Ut 5 2 0 1 NATURAL RESOURCES WAS'pringfielt 62702 21 28 , , AM 0 ❑Construction * c 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM ❑Maintenance U2 Q ARREST NAME / / ❑PM SLMT o U 1 ❑ CITATIONS ISSUES PENDING ROAD CLEARANCE TIME • ❑Utility 2 N ❑ ❑ SECTION CITATION NO. AM 40 2 0 ARREST NAME 91 /01 /024 07 35 ®PM 0 Unknown work zone type Ut % T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 El 1525-Nava.Oscar 701 334-Fries / / El 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 ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r ', ', CO r INDICATE NORTH l. combination) or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver XI } i I ', i -! ` r r r (example.shuttle or charter bus)-or I laar tom.'1 Not To Scale I i i : designed tocarry15 or fewer passengers andoperated contractcar r 0 ----?-----� I -< : } i transporting employee in the course of thir employent(exampleemployeerie M 3. Is } transporter -usually a van nvehicle or passenger r i__ _ A____: : , i r i C a d for direct compensation(example:large van used for specific purpose).or O um I i } i. 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires �i placarding(example placards will be displayed on the vehicle) XI ` L CARRIER NAME Z i. ADDRESS 0 . I r, CITY/STATE/ZIP , : - MOTOR CARR ID ❑ Interstate ElIntrastate 0 Not in Comm./Govt. El Not in Comm./Other ' r , ^ USDOT NO. ILCC NO. , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr 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 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z En Gray - 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