HomeMy WebLinkAbout2024-00065710 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQ035.3503
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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 • 7
0 NOT ON
VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2O24-0006571 O VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 '17
DUNDEE AVE ❑Elgin RELATED ❑Y coN 10 14 2024 03:18 ❑AM ❑YES ®NO U1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW N
❑ FT/MI N E S W Cook ❑Y , , WITH VEHICLES INVLD ❑ STOPPED U2 -I
❑ AT INTERSECTION W HIT&RUN WITH (NAME OF ) PEDALCYCUST El ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIa ❑Nee 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O n
0 9 / 2 4 /1 9 9 5 FOR DAMAGED AREA(S) H1CNT TOWED U1
Heil Co- Tractor w/SemiTrl 2011 00-NONE „ . 12 , DUE TO CRASH El vi
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 i1 2 FIRE ❑ ❑ <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
2137 NICHOLS DR M ❑Y ®SYSNEM❑UNK VEH. O AT CRASH D 0 99-UUNKNOWN 9 16-TOP® ,DistractionValue 9 ALGN
-
r ' POINT OF 9 O COM VEH 0 ® n
CITY PLATE NO. STATE YEAR 'O1
c Z
5HTAM4529B7H75853 AON Risk Services ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 TrueNorth Trucking C CPP137171A 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o 0 y°®EN 10350 BRECKSVILLE RD. Brecksville.OH .44141 (216)621-8100 VEHU
0
m 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PEE ❑PEOAL ❑EQUES 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 21 m
a / / FOR DAMAGED AREA(S) fi20IT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE ,t 12 C
c 13-UNDER CARRIAGE 10 j 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 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value UI 0 -
POINT OF Ca
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II a I_s CIOMes 3eeSideba0 0
C
H F • C
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 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPONDER
YOEl NR Ut =
(UNIT) i SEAT) ;DOB) ISEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
W 08 /1 6/1974 M Shaji Pinarkyil/1389 DUNDEE AVE _ELGIN.IL,6O120/ U2 r
(847)877-7511
/ / #OCCS D
/ / U1 1 m
I I 0
EV MOST EVNT• LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z
1 N 1 ® 24 5 Shell White side barrier 10/14 ,2024 03 18 ®PM in a Work Zone? El DIRP D
I PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1
T 2 0 1389 DUNDEE AVE ELGIN IL 60120 14 28
! / 0 PM ❑Construction *
N t 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o u 1 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N 8AM 10
2 ❑ ARREST NAME / / ptil ❑Unknown work zone type Ut
T • OFFICER ID SIGNATURE BEAT/DIST. •
SUPERVISOR ID. COURT DATE TIME
2 3 ❑ 475-Willians. Brianna 201 334-Fries , / CI PM Workers present? ®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.
0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
.
' r 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 truckrtrailer -<
' r • ; i 'r i- r r , , i r r INDICATE NORTH combination) or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' ` i I ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or
X
; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------.-----• + + • : - 1 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 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
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
T.
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP
, ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
m
r-----.-----, r r r r ,-•---, r '- DO ILCC NO. m
U N XI
, Source of above Z
_ 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 g
Did Carrier Safety Regulations(MCS)violation contribute to the crash% A
❑ Yes No ❑ Unknown 0
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
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Blue
-
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