Loading...
HomeMy WebLinkAbout2024-00063725 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 111111111111110111111011111110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;398 u1 1 U2 3 4 1 U1 4 U2 Ut 1 U2 UI 1 U2 4 6 Ut 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) [Z] B Injury and/or Tow Due To Crash YR 2024I2024-00063725 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'T'I BIG TIMBER RD Elgin ❑ RELATED ®Y ❑N 10 06 2024 03:38 ®AM ❑YES ®No u1 .< PRIVATE mo /day I yr El PM FLOW CONDITION m FT/MI N E S W N STATE ST 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW CI) ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EOUES 0 NIA/ 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n 0 6 / 2 3 /1 9 8 2 Ford Transit Connect 2014 00-NONE FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) . Erick. I. mo day yr 0Q D DUE TO CRASH El ❑ © UNDER CARRIAGE 10 2 FIRE ❑ IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 65 G E N ES E E AVE M ❑Y ISYNM❑UNK VEH. O AT CRASH D 0 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 1 6 j 4 COM VEH 0 ® 1 (7 NMOLS7E70E1173005 Progressive ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER II ' RSUR m Y Same 987806746 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU L ❑Y ®N 2 (7 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NW ❑NCV 0 ov 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 11 12 C c 13-UNDER CARRIAGE 10 I 11 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 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 6 I_S C•IOMes VEH SeeSideba❑ 0 C 1- r REAR 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 < RESPEl DNR Ut 2 (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) C) / / U2 M / /• - m #OCCS ' D / /• U1 1 73 / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ElY U2 Z 1 1 �� 43 1 City of Elgin Street Sign 10,06 ,2024 03 38 ❑pM in a Work Zone? El DIRP co PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 3 C) T 2 0 150 DEXTER CT ELGIN IL 60120 20 28 ❑AM ! I PM ElConstruction * 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 ❑Utility 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME No N AM 45 2 0 ARREST NAME 10/06 /2024 04 00 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 Y 2 3 El ®AM Workers present? 1508-Salgado. Leandro 501 11 / 19,2024 09 00 0 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. 0F 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 if + l 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } ; Tfl ! f -; : combination).or 'I LLB INDICATE NORTHXI , t' : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` } ', , i 1 L ri/1A11 f I. . r r r (example.shuttle or charter bus)-or 3 Is designed to carry 15 or fewer passengers and operated a contract carrier 0 --', ' ' 9 P by -- ® � f } } } transporting employees in the course of their employment(example.employee M i transporter-usually a van type vehicle or passenger car).or w �____A____: : , _i i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N 1 �` ; ; for direct compensation(example:large van used for specific purpose).or ---i i , unlit Poany (HAZMAT) requiresm //// } } 5 Is any vehicle used to transport hazardous material HAZMAT that 1 placarding(example placards will be displayed on the vehicle) 71 ! CARRIER NAME z�r .. ADDRESSTo '�En O • 1 • CITY/STATE/ZIP F , MOTOR CARR ID ❑ Interstate ❑ Intrastate ' : ❑ 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 M 7/ 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? O ❑ 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 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Redmons/Owners Residence SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE