HomeMy WebLinkAbout2024-00067347 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III IIIOII III I
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
ut U2 3 4 1 U1 U2 U1 U2 U1 U2 4 12 U1 U2 *P 9*
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 •
3
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067347 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH '17
N RANDALL RD ® ❑
Elgin RELATED ®Y ❑N 10 21 2024 07:08 DAM ❑YES ®NO Ut .(
PRIVATE mo /day/yr ®PM FLOW CONDITION m
iP0 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW N
®/MI N E OS W Foothill Rd 'WITH VEHICLES INVLD CISTOPPED U2 —I
p AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ElY ® N PEDALCYCUST®N ® FREE FLOW # LNS 0
❑0RNER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EOUES 0 NW 0 Ncv 0 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 ❑ ❑
DUEFIRE TO CRASH El El
(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 76-TOP 3
.1—
❑Y ❑N ❑UNK VEH. AT CRASH POINT OF
8 {I� -4
COM VI EH ion�� ALGN
CITY PLATE NO. STATE YEAR it 6 0 0 n
FIRST CONTACT 7__.REAR
-1 6 "If Yes,See Sidebar U1 0
ID VIN INSURANCE CO. EXPIRED
o El DN U2 m
m RSUR
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER m
z _ 1 I—
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER VEHU D
o ❑Y ❑N 0❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 Xi
C
a 13-UNDER CARRIAGE 10 I I 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR 0
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
El Y p N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1
POINT OF VEH N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 6 I-5 CIOMes.See Sidebar
❑ C
to
H �� • Cl)
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 C
RESPONDEO ElNR Ut I
(UNIT) (SEAT) (DOB) (SEX) )SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'/-(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL) n
2 3 1 1 /04/2006 F 2 4 0 1 0 Madissen S. Wallentin/1205 N LANCASTER CIR.SOUTH ELGIN.IL.60177 Refused r
(630)965-6865 , U2 m
/ / #OCCS D
- _ X
/ / Ut mm
I I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z
N 1 El 10/21 /2024 07 31 ®pM in a Work Zone? ElN DIRP co
T 2 ❑
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1
t
! I PM El Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
•
ARREST NAME / / ❑PM SLMT
o u 1 I� CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' ❑Utility
o N SECTION CITATION NO. AM
¢ T
2 ❑ ARREST NAME 10/21 /2024 07 59 ®PM 0 Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ElY
476-Ramos.Clarissa 602 334-Fries / / 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 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
, . r r r r , , , , . r0 .
z
1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` ', ', ! i. ` ' ' 1 ', ' I. ` r r r (example.shuttle or charter bus)-or 0
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----i-----a a a I t • : - -, I + i } - t transporting employees in the course of their employment(example.employee X1
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
r 9 Po P 9 N
for direct compensation(example:large van used for specific purpose).or O
11
i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) M
•
CARRIER NAME Z
' ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate El Intrastate <
• . ❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
•• , • Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
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 X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles 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% p
❑ 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 CJ
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? T
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't z
• 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