HomeMy WebLinkAbout2024-00064180 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III H II Hil mil U II IID HID DI 1111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00064180 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y ❑N 10 08 2024 ®AM ❑YES ®NO U1 -<
W HIGHLAND AVE Elgin07:44
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT l MI N E S W N MELROSEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 1 2 /
yr 13-UNDER CARRIAGE ( ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U NI
O DISTRACTED 0 0 U2 2 rn
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI ii,4 COM VEH 0 El 1 0
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TELEPHONE
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in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
0 DRIVER ❑ PARKED 0 DRIVERLESS gi FED 0 PEDAL 0 EWES 0 IIUV 0 NCv 0 CIRCLE NUMBER(S) U1
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13-UNDER CARRIAGE 10 I 2 FIRE 0 El U2 C
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❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i1�I-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 15 7�� =.5 •Iryey,See Sidebar C
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❑Y 0 N RDEF 71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 49 2 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPOND
❑N u1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 08 /
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 12 4 10,08 l2024 07 44 ®❑PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
2 0 12 4 14 23 10,08 /2024 07 45 Pse
I ❑ ❑Construction >F
R 3 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ®AM ❑Maintenance U2
-a, ARREST NAME Fazel.Chad.A. 11-1002.5 1545000001 10/08/2024 07 52 ❑PM SLMT
o u1 ® 11 4 •El CITATIONS ISSUED 0 PENDINGTIME ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE DI AM 20
r 2 0 ARREST NAME Fazel.Chad.A. 11-601-Ax 1545000002 , / PM 0 Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 20
1545-VanEycke. Brier 601 404-Duffy / / ❑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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
} }----r___-; I combination):or more than pounds(example:truck ortruckrtrarler 1. Has a weight rating10 000i -<
INDICATE NORTH Ilon) p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
Not To scale (example:shuttle or charter bus):or 0
I3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
A }} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or co
LI 4. Is used or designated to transport between 9 and 15 passengers,including N
--- ----; / - } } } g po passen rs,indudi the driver,
for direct compensation(example:large van used for specific purpose):or
L L____a____; mar _ L L L I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
unit D
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placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME Z
I _ ADDRESS 0
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I CITY/STATE/ZIP V)
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MOTOR CARR.ID 0 Interstate 0 Intrastate
l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
x
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. z
White
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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE