HomeMy WebLinkAbout2024-00066345 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III III III I
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON
VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066345 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH '11
N MCLEAN BLVD ❑Elgin RELATED ®Y ❑N 10 17 2024 09:47 ®AM ❑YES ®NO U1 .(
PRIVATE mo /day/yr ❑PM FLOW CONDITION m
Fri MI N E S W LAR KI N AVE 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR 0 SLOW CI)
❑ 'WITH VEHICLES INVLD El STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O
❑DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGED AREA(S) FRONT_ TOWED U1 0
00-NONE 11 12 1 DUE TO CRASH ID E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 76-TOP 3
r ElY ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN
& {I 4 Distraction
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CITY PLATE NO. STATE YEAR it 6 COM ER ❑ 0 n
FIRST CONTACT 7__.REAR
5 "If Yes,See Sidebar U1 0
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. ID VIN INSURANCE CO. EXPIRED
o ❑Y D N U2 m RSUR m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER m
1 I—
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER VEHU D
•L El El 0m ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUN ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 C
a 13-UNDER CARRIAGE 101 j 2 FIRE ❑ ❑ U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPUR 0
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1
POINT OFCO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe6 VEH
SeeSideba❑ ❑ C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑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 PHONE NUMBER C
D YOEl N Ut =
(UNIT' (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)t(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 - El - 10/17 /2024 09 47 pM in a Work Zone? ®N DIRP CO
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 0 T 2 0
t
oi ! , PM El Construction *
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
ARREST NAME / / ❑PM SLMT
o U 1 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N B AM
2 0 ARREST NAME r / ppl El Unknown work zone type U1
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ElY
218-Wilson.Greg 602 272-Bajak t , 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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
' i. A CMV is defined as any motor vehicle used to transport passengers or property and. Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' r 1 ; i ; i- r r , , i INDICATE NORTH combination).or —I
XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', ! ' ' 1 ', ' 1. ` r r r (example'.shuttle or charter bus)-or n
S
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
-----'-----• + + • l- .- J 1 1 1 i } - i• transporting employees in the course of their employment(example.employee XI
' I
transporter-usually a van type vehicle or passenger car).or 03
' r i• 4 Is used or designated to transport between 9 and 15 passengers,including the driver,
9 Po P 9 N
for direct compensation(example:large van used for specific purpose).or O
' 1 i i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) 71
M
CARRIER NAME Z
' .. ADDRESS 0
N
. O
CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ❑ Not in Comm./Other Q
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r-----.-----, r r r r ,-•---, r - DO ILCC NO. m
U N 71
, • Source of above z
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. IDOT PERMIT NO WIDELOAD? ❑Yes ❑No =
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
(7
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ z
-74
TRAILER 2 ❑ ❑ ❑ o
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. y
• - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
U_TOWED ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO
DUE 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