HomeMy WebLinkAbout2024-00065111 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 M 01011111111 II
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003585697*
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 202412024-00065111 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -1
NESLER RD Elgin 08:54
® ❑ RELATED ®Y ❑N 10 11 2024 12— ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W GANSETT PKWY COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR El SLOW Cl)
❑ Kane HIT ❑V ® N WITH VEHICLES INVLD El STOPPED U2 --I
® &RUN 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 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
0 3 /
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13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 SYTM 5 ❑Y ®SNE DUNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 t6•TOP 3 *Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �i 4 COM VEH 0 Ea 1 0
ELGIN I L 60124 0 1 0 FIRST CONTACT 11 7_:, __5 *lI Yes.See Sidebar U1
Z EX55570 IL 2025 REAR
TELEPHONE
IL 0 4T1 BK1 FK000008027 PROGRESSIVE ❑Y ®N U2 n-i
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 985378652 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 rg- ou
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr 12 _ C1
.0 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR n
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraclionvalue U1 4 -
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I._
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 36 2 City of Elgin Tree 10/11 /2024 08 54 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
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PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 41 2 150 DEXTER CT ELGIN IL 60120 28 15 10!11 /2024 08 54 PM
1 ® • El Construction >F
R 3 ❑ 2 1 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ❑AM 0 Maintenance U2
-a, ARREST NAME Johnson. Kevin. R. 11-601 1532-000297 10/11 /2024 09 01 ®
o1 PM SLMT
U 0 ig!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM' ❑Utility
t 2 ElARREST NAME Johnson. Kevin. R. 11-503-A 1532-000296 10/11 /2024 10 16 ®PM 0 Unknown work zone type U1 45
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? 0 Y
1 542 Chafe. Ethan 801 11 ! 18,2024 01 30 ®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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is L L.___A_. 1 i. <--_- -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or CO
< <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ,.___-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
i.
ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 UnknownT.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 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
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage 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