HomeMy WebLinkAbout2024-00063744 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III III III I
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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 1
0 NOT ON
VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00063744 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 '�'1
DUNDEE AVE ❑Elgin RELATED ❑Y coN 10 06 2024 08:51 ®AM ❑YES ®NO U1 ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
0 N 'COUNTY PROPERTY El M N DOORING ❑y #OF MOTOR ❑SLOW CI)
®/MI OE s w Cooper Ave WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS O
NI DRIVER ❑ PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FRONT TOWED U, O
mo day yr 13-UNDER CARRIAGE 1, 2 FIRE 0 IA
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SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
11 CLAM M E CT F ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 15-OTHER
99-UNKNOWN 9 16-TOP 3 .Distraction Value 9 ALGN 2
r CITY PLATE NO. STATE YEAR POINT OF 8• !1 6 it 4 COM VEH 0 ® 1
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JTN KH M BX9 K1045949 Progressive ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Same 971822191 1 r
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU X
L ❑Y ❑N 2 (7
m 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 ou DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1
Y N m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi , DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 C
c 13-UNDER CARRIAGE 101 j 2 FIRE ❑ ❑ U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR 0
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value UI 9
POINT OF 03
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_11 61_5 C•IOMes 3eeSideba0 0
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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 996 <
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(UNIT) (SEAT) (DOB) (SEX) ;SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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/ / - #OCCS D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 1 10/06 /2024 08 51 ❑pM in a Work Zone? ®N DIRP
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T 2 0
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 0
a
! , 0 PM El Construction *
N 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o U 0 0 CITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N BAM 35
2 0 ARREST NAME ( / ptil ❑Unknown work zone type Ut
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 El
483-Lynch, Miriam 200 272-Bajak ( , ❑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.
r 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
1 . r r r r , , , , . r0 .
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1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` ; ; ', ', ; ! i. ` ' ' a. ', ' I. ` r r r (example.shuttle or charter bus)-or 0
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----i-----a a a I t • : - -, I I + i } - t transporting employees in the course of their employment(example.employee 71
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
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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) "0
1.
CARRIER NAME Z
' ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate ❑ Intrastate <
❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
•• , • Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
z
GVWR/GCWR —I
❑ <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles 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% p
❑ 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 CJ
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? T
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
u 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't z
White
U 3 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