HomeMy WebLinkAbout2024-00066467 (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 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066467 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT
RESERVE DR ❑Elgin RELATED El Y coN 10 17 2024 07:57 ❑AM ❑YES ®NO Ut ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
��'0 /MI N E S W AN NA Way 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW CI)
. Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
❑DRIVER Cg PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑ECUES 0 NW ❑Nee 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1
Ford Escape 2008 00-NONE N 12 , 1 DUE TO CRASH ❑ 21 - E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 1 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 El U2 m
O O 9 16-TOP 3
/ ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value ALGN
r CITY PLATE NO. STATE YEAR POINT OF i_167 _ COM VEH 0 ® 2 O
I— FIRST CONTACT 6 7__,{REnR 5 'It Yes,See Sidebar U1
Z DH76657 IL 2024
. ID VIN INSURANCE CO. EXPIRED
Cr' 1 FMCU93188KE29182 USA INSURANCE ❑Y ®N U2 m
m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Y 99 9 ESTRELLA.JAIME GIC 44070889 7102 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
L RESPONDER 1145 RESERVE DR. Elgin. IL.60124 (847)915-8971 VEHU 6)
m ❑DRIVER 0 PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi 1 DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
c 13-UNDER CARRIAGE 10 i 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 SPOR 0
Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value Ut 0 -
El
POINT OFCa
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 6 l_5 C•IOMes 3eeSideba❑ 0 C
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REAR
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
YOD NR Ut =
(UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
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I I - #OCCS D
/ / Ut O D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur IDY U2 Z
N 1 ® 18 1 10,17 /2024 07 57 ®PM in a Work Zone? ®N DIRP
D
T 2 ❑
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM I1 YES check one below: U1 1 C)
a
/ ( 0 PM El Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o U 1 ❑ 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N 8 AM 30
2 El ARREST NAME , / pti1 ❑Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ ®AM Workers present? El Y
218-Wilson.Greg 801 272-Bajak 11 , 12,2024 01 30 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.
r 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. Z
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1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I
• M
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' •_ ', ', ! i- ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or
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; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------i-----• + + • : - -, 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 03
' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers 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
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placarding(example placards will be displayed on the vehicle) .Z1
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. `
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP n
, ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r r•---, i - DO ILCC NO. m
U N XI
, Source of above Z
. GVWR/GCWR —I
❑ <10,000 0 10,000-26,000 0 >26,000 Z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No PJ
7)
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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 D
Did Carrier Safety Regulations(MCS)violation contribute to the crash
❑ Yes 0 No ❑ Unknown A
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
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 3 COLOR U_COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Beige
-
U 3 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