HomeMy WebLinkAbout2024-00065754 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111111111 10 111110111 Ill II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003539542-
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00065754 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 '�7
N LYLE AVE Elgin ID
❑Y co" 10 14 2024 06:55 ❑AM ❑YES ®No u1 .<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
5 COUNTY PROPERTY ❑Y ®" DOORING ❑'' #OF MOTOR ❑SLOW CI)
®2 ®I MI ON E S W LARKIN Ave 'WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
DA DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑ECUES 0 NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED Ut 0
Chevrolet Silverado 2019 00-NONE DUE TO CRASH
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NAME(LAST,FIRST,M) .Giovanni mo day yr 11-1 ,2 D ❑ ISl
,3-UNDERCARRIAGE io) 2 FIRE ❑ ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
216 PAU LI N E DR M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN =
CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 El 1 0
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1 GC1 KSEG8KF108642 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Same 2129012SFP13 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®" 2 G1
' ❑DaNER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH U1
MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fii DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 C1
c 13-UNDER CARRIAGE 101 2 FIRE ❑ ❑ 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 SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value UI 0 -
POINT OF
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe53eeSideba❑ 0 C
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REAR C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
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❑Y ❑N RDEF
EMS AGENCY I PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
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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&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
1 N 1 0 1 3 City of Elgin Fire Hydrant 10/14 /2024 06 55 ®pM in a Work Zone? ®N DIRP coe.t
PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1
T 2 El 43 3 150 DEXTER CT ELGIN IL 60120 10 99
! / 0 PM ❑Construction *
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N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
ARREST NAME / / ❑PM SLMT
,- U 1 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
30
¢ 1 2 ❑ ARREST NAME / / 8 pMAM 0 Unknown work zone type Ut
Fo T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 ❑AM Workers present?
El1507 Ruiz.Alondra 602 334-Fries / p 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 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. Z
r- -r--- 4 , 4 r r r r r , , , 1 . r
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' r •• ; i ; i- r r , , i r r INDICATE NORTH combination) or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or
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; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or w
' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver,
9 Po P 9 N
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) 11
•
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP O
, ,
MOTOR CARR ID ❑ Interstate ElIntrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r r•---, r - DO ILCC NO. m
U N XI
, Source of above Z
. If Yes, Name on placard O
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 D
Did Carrier Safety Regulations(MCS)violation contribute to the crash
❑ Yes 0 No ❑ Unknown A
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
Form Number 0
M
X1
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
CJ
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Silver
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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