HomeMy WebLinkAbout2024-00067289 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III (IIIIII II 111111111111111110111 1111110110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
3
0 NOT ON SVEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00067289 VENT *
ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT
S RANDALL RD ® ❑
Elgin RELATED El Y co" 10 21 2024 03:53 ❑AM ❑YES ®No u1 • ,•<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
5 0/MI N O E S W HoppsRd 'COUNTY PROPERTY ❑Y 21 N DOORING ❑Y #OF MOTOR CI SLOW CI)
WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0
tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW 0 RDV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
mo dayO
LEAL, NazikHonda Accord 2005 00-NONE ®; 12 , DUE TO CRASH El ❑
NAME(LAST,FIRST,M) yr ,3-UNDER CARRIAGE t _ 2 FIRE ❑ I21 E
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ISl U2 m
488 DIVISION ST F SYSTM❑Y El NE❑UNK VEH. O ATCRASH D O 15-99-UUNKNOWN THER9 16-TOP 3 "DislractlonValue ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8 116 li COM VEH 0 ® 1 0FIRST CONTACT 11 T 1_ �5 "If Yes,See Sidebar 1.11 0
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
a Same ILP3427563 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
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m 0 DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV U1
DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 73
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c 13-UNDER CARRIAGE 10 I I 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.1I 61_5 CIOMe53eeSideba❑ ❑ C
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(UNIT) (SEAT) (DOB) (SEX) )SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS 8 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 ❑AM Did crash occur El U2 Z
N 1 ® 2 3 co
10/21 /2024 04 27 ®pM in a Work Zone? El DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C)
T 2 ❑ 10 18
! I 0 PM ❑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 I ❑ CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ❑Utility
o N SECTION CITATION NO. AM 45
2 ❑ ARREST NAME 10/21 /2024 04 51 ®PM 0 Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ CIAM Workers present? El
476-Ramos.Clarissa 801 - / / ❑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.
_ 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
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r ; ; I ; ; combination) or XI
NDICATE NORTH
N I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
XI
J. I d i I -` ` r r r (example'.shuttle or charter bus)-or
X
i.-----i_----� -t t } t designed
employeeslin the courseaof theiremployment(example�emaployeerie OM 3 Is
� } trans
Vansporter-usually a van type vehicle or passenger car) or w
i_____A____: : i , : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C
$ for direct compensation(example:large van used for specific purpose).or
___: , I ,''' _t I' I- 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires O
placarding(example placards will be displayed on the vehicle) Zml
CARRIER NAME Z
' I ADDRESS 0
to
H ±� CITYlSTATE/ZIP
am
Not 7b Scale MOTOR CARR ID ❑ Interstate ❑ Intrastate
r , ,
0 Not in Comm./Govt. Not in Comm./Other
USDOT NO. ILCC NO.
• , Source of above 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? 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
Form Number 0
m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. y
Silver
U 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑,r DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO-
Other/Impound Lot Garage 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