HomeMy WebLinkAbout2024-00067353 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III (III (IIIIII II 111111111111111110111111111111011
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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 •
15
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067353 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
BIG TIMBER RD ® ❑
Elgin RELATED ❑Y coN 10 21 2024 07_38 ❑AM ❑YES ®No u1 • ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
®10 0/MI NOS S W WHITE OAK
) PEDALCYCUST® ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 SIN 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
. Morgan, M. 1 0 / 1 2 /2 0 0 5 Mazda 3 2015 00-NONE „t 1Y , DUE TO CRASH p 21E
NAME(LAST,FIRST,M) g mo day yr ,3-UNDER CARRIAGE �0 1 2 FIRE 0 ISl <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Igl U2 m
11 N253 ROMEO DR F ❑Y El NSYSTEM❑UNK VEH. 0 AT CRASH D 0 99-UUTHER NKNOWN 09 16-TOP 3 •Distraction Value 9 ALGN =
CITY PLATE NO. STATE YEAR POINT OF ®fl 6 ii 4 COM VEH 0 ® 1 O
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in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
a 99 9 Woodhouse. Kenneth, D. 5440988401 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r
o RESPONDER 11 N025 ROMEO DR. Elgin , IL.60124 (630)209-3596 VEHU 0
❑DRIVER El PARKED ❑DRNERLESS ElPEE ❑PEDAL ❑EQUES ❑SUM ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
a / / FOR DAMAGED AREA(S) F0 4T TOWED Y N
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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 n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value UI 0
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(UNITE (SEAT) (DOB) (SEX, (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME'/IADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
1 3 07 /02/2005 M 2 4 0 1 0 Micaiah D. Bovey/143 CONNDE ST.West Chicago.IL.60185 r
(630)501 5868- U2 m
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 16 1 Illinois Department of Natural Resources Deer 10,21 ,2024 07 38 ®PM in a Work Zone? Ill N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AMU1 3
2 ❑ 1 NATURAL RESOURCES WA1i'pringfieldL 62702 21 99 , , ph,
0 ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
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o N Hz 0 45
2 ❑ ARREST NAME , / Unknown work zone type Ut
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• OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ElY
1506-Nunez. Maria 502 334-Fries , , ❑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.
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 ; i- r r , , i r r INDICATE NORTH combination) or —I
."0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' ` 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 i } - i• transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or w
J. 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 El Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r ,-•---, i - DO ILCC NO. m
U N XI
, Source of above Z
. If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No M
7)
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 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 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- 2 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