HomeMy WebLinkAbout2024-00067481 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away
Elgin Police Department ONE PERSON'S Ed$501-$1.500 ®ON SCENE 1
EI NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00067481 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 11
N MCLEAN BLVD ® ❑
Elgin RELATED ❑Y coN 10 22 2024 02:21 ❑AM ❑YES ®NO U1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
®1 0 ®/MI N E S® EASY St 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW CA
Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD IZ) STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ❑ FREE FLOW # LNS 0
ig DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 TOWED U,
0
0
ONT
, Hu o 0 3 / 1 7 J 1 9 9 8 Nissan Murano 2011 00-NONE FOR DAMAGEDAREA(S) FR11 12 i' , DUE TO CRASH p ® - E
NAME(LAST,FIRST,M) g mo day yr 13-UNDER CARRIAGE 19 1 2 FIRE 0 l$1 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
1760 MARK AVE a M ❑Y ISYNM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN =
T. CITY PLATE NO. STATE YEAR POINT OF a i_167 4 COM VEH 0 El 1 0
a ~
JN8AZ1MW2BW163459 No insurance ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn
99 9 Same No insurance 2 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU 73
L ❑Y ®N 2 GI
m ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NUN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi i DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 11_ 12 7
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
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPUR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN e 4 •Distraction Value UI 0 -
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POINT OF I
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_)1 a I_5 CIOMe6 VEH
SeeSideba❑ ❑ C
to
H R • C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF73
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 <
DYOIDN Ut I
(UNITE (SEAT) ;DOB) ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONE) {EMS) (HOSPITAL) n
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/ / - #OCCS D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ElY U2 Z
N i ® 11 1 10/22 /2024 02 21 0 pM in a Work Zone? ®N DIRP
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T 2 ❑
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C)
a
/ I 0 PM El Construction *
c' 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 PENDING ROAD CLEARANCE TIME ❑Utility
o N ❑ ❑ SECTION CITATION NO. AM 40
2 0 ARREST NAME 10/22 /2024 03 15 ®PM 0 Unknown work zone type U1
% T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ 1507-Ruiz.Alondra 602 334-Fries 11 / 12/2024 01 30 0 pM Am Workers present? ®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 1 . r r r r , , , , . r .
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 I ; ! i. ` ' ' '. ', ' l' ` 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 + 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
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
1.
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 E
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 3 COLOR uCOLOR TRAILER LENGTH(S)1 ft 2 't 2
Black
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