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HomeMy WebLinkAbout2024-00063791 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III II 0 lu II 11111111111111011111111H 1111 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XDO35;T;3r2` u1 9 U2 1 1 1 U199 U2 1 U1 99 U2 U1 99 U2 1 1 9 U1 1 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 SCENE • 1 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash yR 20241 2 024-0 0 0 6 37 91 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 INDIAN DR ®gin El ❑Y co" 10 05 2024 04'OO ❑AM ❑YES ®No u1 -< PRIVATE mo /day/yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y M N DOORING ❑y #OF MOTOR ❑SLOW 1 U1 ❑ FT/MI N E S W Cook HIT&RUN ®Y ❑ N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS ' 0 D4 ORNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 .0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 .r 2 FIRE 0 Ill < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m M SYSTEM IN g ENGAGED 9 15-OTHER 9 16-TOP 3 I ❑Y ❑N El UNK VEH. AT CRASH ®-UNKNOWN Distraction Value g ALGN r CITY PLATE NO. STATE YEAR POINT OF 8 1t 6 ii 4 COM VEH 0 El 1 m I— UNKNOWN UKNOWN ®Y ❑N U2 r m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same UNKNOWN 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU L ❑Y ® Same" 99 0 i. ❑DRIVER ® PARKED 0 CRNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 KW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) •Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) mo day yr Lexus NX 20DT 2017 00-NONE 11 r 12 I.D DUE TO CRASH ❑ ® 1 73 c 13-UNDER CARRIAGE 10 j I: 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER Og 16-TOPO 0 ® SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 Distraction Value g U1 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II I COM VEH ❑ ® C FIRST CONTACT 1 7_- a =5 •It Yes,See Sidebar CU17637 IL R 0 n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JTJBARBZXH2107804 Allstate ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Mosley-Sheena. L. 962995466 BAC ' E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER E 1121 INDIAN DR. ELGIN . IL,60120 (630)883-8586 U1 = (UNIT) (SEAT) (DOB) ISEX) ;SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS Si WITNESS ONLY (NAME)I(ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL) n I I - U2 996 1— m /• / - - '#OcCS D / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 18 1 10,06 /2024 03 30 0 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 99 ! / 0 PM ❑Construction * 1 c' 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM ❑Maintenance U2 3 Q 1 ® 11 1 ARREST NAME / / ❑PM SLMT o U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility p N AM 15 T 2 0 ARREST NAME 10/06 /2024 03 30 ®PM ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1500-Chew. Marie 201 - / / Q AM Workers present? ®N U2 15 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. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } 1 i i combination) or INDICATE NORTH XI I ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. J. ', i -! ` r r (example shuttle or charter bus)-or 7 0 J 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----;----- 4 1 -f t t } } transporting employees in the course of their employment(example.employee ,3 Not To Scale I i transporter-usually a van type vehicle or passenger car).or CO i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O jj , 1121?tndlen?Dr. < < ;, 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) m Z1 CARRIER NAME Z °� ADDRESS 0 N • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. Not m Comm./Other 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 D Did HAZMAT Regulations violation contnbute to the crash? ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID 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 5 Z Form Number 0 _ m xi IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver - 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE