HomeMy WebLinkAbout2024-00065824 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 M h
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00358 462*
u, 9 U2 1 1 1 U1 99 U2 U199 1_12 U,99 U2 1 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1,500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00065824 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ®Y 0 N 10 15 2024 ®AM ❑YES ®NO U1 -<
LINDEN AVE Elgin06:55
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
75 !MI N E S W Liberty St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® ® O Liberty WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ❑ N PEDALCYCLIST®N 51 FREE FLOW # LNS 0
tg DRIVER (] PARKED D DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
$ 4
'a- CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -1_B 1i.- COM VEH 0 ZgJ 1 0
H 0 9 FIRST CONTACT 99 7_: _5 *IrYes,See Sidebar U1
REAR
2 Z ' E
TELEPHONE
IL Other NIA ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Same NIA 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r 0 Y°N0 N 0
W p DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 My 0 KCV 0 Dv
yr 13-UNDER CARRIAGE 11 112 1 FIRE 0 ® U2 C
II
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ® SPDR 0
0 Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 9 -
POINT OF s-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 O 7 . Its •CIO e1s.See SidebarEH ❑ ® CO
H DC16602 I L 2024 I:EaR9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G1 PA5SH6E7440386 Progressive ❑Y ISI N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Russell.Andrew. M. 928964399 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 9 10,15 l2024 06 55 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 11
N 1 3 0 0 CITATIONS ISSUED 0 PENDING + ! _ 0 pM, 0 Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
-a, ARREST NAME / / 0 PM '
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
25
t 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
1504 Real, Hilario 302 272-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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
.. .. , N A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To Scale I 1 Has
eight rating more than 10,000 pounds(example:truck or truck trailer
1.
r �----r----, - - 1. INDICATE NORTH -1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
a, _ } (example:shuttle or charter bus):or
a ,
ta
r` 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
I- }-----I----; z - 1. } } . transporting employees In the course of their employment
pbyment(example:employee P71
transporter-usually a van type vehicle or passenger car):or w
i. }-----}. ..I. - • I I 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
C
Linden?Ave. for direct compensation(example:large van used for specific purpose):or O
L a l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
Urikis placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME Z
ADDRESS 0
CO
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
1- - --1. - USDOT NO. ILCC NO. rn
73
Source of above z
. GVWR/GCWR m
❑ <10,0oo 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
73
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations MCS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
to
LOCAL USE ONLY TRAILER VIN 2 m
O
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 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 g TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE