HomeMy WebLinkAbout2024-00065810 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 10
VEHICLE/PROPERTY ®OVER 51,500 0 NOT ON SCENE(DESK REPORT)
0 AMENDED ® B Injury and/or Tow Due To Crash yR 2024I 2024-0006581 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
20 N CRYSTAL AVE El In 02:22
® ❑ RELATED 0 Y ®N 10 15 2024 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI NESW 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 O
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Unknown.0. mo / / yr Chrysler 300 2015 00-NONE 0O 0DUE TO CRASH ® ❑
13-UNDER CARRIAGE cy O FIRE 0 ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2
* �T1
1 $ SYSTEM IN O ENGAGED 0 15-OTHER 00 70P�3 _
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 li,4 COM VEH 0 Zg! 1 O
I- A 4 0 FIRST CONTACT 1 7 ; _-5 *lI yes.See Sidebar U1
Z EW79008 IL 2024
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED
D 2C3CCAGG9FH887524 General Auto Ins ❑v ®N r-
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.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire M EN DOZA.ANA 1 B-I L7127455 1 r
`5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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m ❑ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0
yr 12 _ C1
o 13-UNDER CARRIAGE 10.i :., FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR O
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7 6 1,_5 CIO Ms See SidebarEH
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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 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
1 2 05 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
1 1 0 1 3 Elgin Automatic Transmissions East wall(brick&window) 10,15 /2024 02 22 ®❑AM in a Work Zone? ®N DIRP D
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)T 2 ® 42 3 F.; t 20 N CRYSTAL AVE ELGIN IL 60123 20 19 r r ❑PM El Construction *
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ElPM '
o N1 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility SLMT
30
t 2 ARREST NAME AM
r r ❑❑PM ❑Unknown work zone type U1
El
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑y
457-Fearol. Megan 601 360-Yucaitis r / 0 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):. Hasor more than pound (example:truckortrucktrailer 1. Has a weight rating10 000 5
, INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I
i_ xirlel POI
} e. (example:shuttle or charter bus):or 0
Ave.' A 3. Is designed to carry 15 or fewer passengers and operated by a contract corner I O
} } } transporting employees In the course of their employment(example:employee 73
I transporter-usually a van type vehicle or passenger car):or
-- } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
u, a-•------�.��._.._.. _ � for direct compensation(example:large van used for specific purpose):or O
ratcrymitkol ik ..2 l. I. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
II 1 placarding(example:placards will be displayed on the vehicle). m 0
- _ CARRIER NAME Z
i. ADDRESS
D NitillalloncaNn. C/7
I I c D CITY/STATE/ZIP 0
Not To Scab I - MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes II No ❑ Unknown 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 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE