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HomeMy WebLinkAbout2024-00063246 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III )III IIIIIII II 111111111111111111111111111111H II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00357:260' u1 9 U2 1 1 1 U1 9 U2 1 U199 U2 1 U1 99 U2 1 4 9 U123 U221 *P 0119* 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 SCENE0 NOT ON 1 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063246 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 MEAGAN CT ❑Elgin RELATED ❑Y co" 10 03 2024 08:09 DAM ❑YES ®NO U1 .< PRIVATE mo /day I yr ®PM FLOW CONDITION m ®20 ®I MI N E S® Toastmaster ) PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 DRIVER ❑ PARKED ❑ORNERLESS ❑ FED ❑PEDAL ❑EOUES ❑NIA/ ❑NCV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 .0. Unknown Unknown Do-NONE 11 21 is i' , DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDERCARRIAGE t91 2 FIRE 0 ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 0 ® 01 M SYSTEM IN ENGAGED 15-OTHER DISTRACTEDU2 9 16-TOP 3 r M ❑Y ❑N ❑UNK VEH. AT CRASH POINT OF UNKNOWN 8 it ii 4 COM VIER ion�� 0 ® ALGN CITY PLATE NO. STATE YEAR } 6 1 F Unknown ❑Y ❑N U2 r m M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 99 GI m ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut Y N m m / / FOR DAMAGED AREA(S) FRONT TOWED —I Infiniti G37X 2009 00-NONE It' © _t DUETO CRASH ❑ 21 1 73 NAME(LAST,FIRST,M) mo day yr 10 jl 2 FIRE ❑ U2 C c 13-UNDER CARRIAGE ® c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value U1 9 POINT OF e . 4 cgi N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ H FIRST CONTACT 12 7.-�-6 5 Itvee,See Sidebar C DC61781 IL 2024 REAR O fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JNKCV61 F69M365713 United Equitable Insuranc ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same PPW1317953 enc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N El Same Ut i (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EIMSi (HOSPITAL) I I 0 - uz 996 1- m / / - - #OGCS ' D / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 18 1 10;03 /2024 08 09 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 0 T 2 0 18 18 ! / 0 PM El Construction * N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM El Maintenance U2 3 Q 1 ® 11 1 ARREST NAME / / 0 PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 20 T 2 0 ARREST NAME I / ptil ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑ Workers present? 1 509-Wortman.Cassie 201 - I / Q PM ® 20 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 f AD DITIONAL UNITS FORMS Not To Scale 0 r_.._r____ 1 1 _, _ - _� } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r I { ; Q combination) or INDICATE NORTH r"0 iv I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC .' ', i -l' ` r r r (example'.shuttle or charter bus)-or ll X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t------;-----% 1 -i } - i- transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w -------------: : ; ��- : : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose).or O :____--___-; 1 1 : 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires �= 11 placarding(example-placards will be displayed on the vehicle) Zml D CARRIER NAME Z ToeatrneaterTOr 0 ' t ADDRESS N • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate El Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 71 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 XI 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 2 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- 9 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE