HomeMy WebLinkAbout2024-00065751 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III IIII IIIIIII II 111111111111111110111 11111111101
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E4;9-
u1 9 U2 3 4 1 U1 5 U2 U199 U2 U1 99 U2 1 6 Ut 1 U2 *P 0119*
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 2
El NOT ON S
VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ElB Injury and/or Tow Due To Crash YR 2024I2024-00065751 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH gg -n
NATIONAL ST ® ❑
Elgin RELATED ®Y ❑" l O 14 2024 06'23 ❑AM ❑YES ®No U1 -<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W S STATE ST 'COUNTY PROPERTY El M N DOORING ❑y #OF MOTOR 0 SLOW CI)
❑ 'WITH VEHICLES INVLD El STOPPED U2 —1
El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN (23Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0
DI DRIVER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1
mo NAME(LAST,FIRST,M) day yr
.0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH p 21
13-UNDER CARRIAGE 10) 2 FIRE ❑ Ill <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 ® U2 m
9 76-TOP 3
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CITY PLATE NO. STATE YEAR T { 6 i( COM EH2
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ID VIN INSURANCE CO. EXPIRED
UNK El El U2 m
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>. RESPONDER S VEHU
L ❑Y ® Same 99 GI
❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 C
c 13-UNDER CARRIAGE 10 I 11 2 FIRE ❑ 0 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 SPOR n
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1 0 -
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II 61_5 C•IOMe53eeSideba❑ ❑ C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
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EMS AGENCY 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) (INJ) (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME),(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) C)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 3 Department of Transportation Traffic Light Pole 10/14 ,2024 06 23 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7
2 ❑ 2300 S DIRKSEN PKWY Springfield. 62764 20 06 / , PM
0 ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / _ El PM SLMT
o U 1 0CITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Utility
o N 0 ❑ SECTION CITATION NO. AM 30
2 0 ARREST NAME 10/14 /2024 08 00 ®PM 0 Unknown work zone type U1
% T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? ❑
1526-Walsh.Jacob 701 246-Kite , El PM ®" 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.
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.
D
Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I 1 INDICATE NORTH combination) or
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i ', d i i -t ` 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
f•----.....---% 4i //JJJ I -i } - i transporting employees in the course of their employment(example.employee ,3
vehicle or
ca
i_____A____: : , / mmeauwrt i r i- 4a Is usedror designated to trra-usually a van nsport between 9 and
15rpassengers,including the driver, N
for direct compensation(example:large van used for specific purpose).or
--4 ; . .. i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example placards will be displayed on the vehicle) 71
` L CARRIER NAME Z
i. ADDRESS 0
N
• : llrtsire.; C)
• CITY/STATE/ZIP 0
,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
USDOT NO. ILCC NO.
, Source of above Z
. ❑ Yes ❑ No ❑ Unknown g
Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID
Yes No ❑ Unknown 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 C
z
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
m
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
-
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