HomeMy WebLinkAbout2024-00066982 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III HI
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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 ®$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 2024I2024-00066982 VENT *
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
SPRING ST RELATED ❑Y coN 10 20 2024 01'48 ®AM �� YES 0 NO u1 ,<
Elgin PRIVATE mo /day I yr ❑PM FLOW CONDITION m
1 COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW CI)
® ®I MI N E OS W River Bluff
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O
❑DRIVER Ig PARKED ❑ERNERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Honda CRV 2012 00-NONE 11 12 ' 1 DUE TO CRASH ❑ 21
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 IA <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN n ENGAGED O 15-OTHER DISTRACTED 0 El U2 m
9 16-TOP 3
El Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value ALGN
r CITY PLATE NO. STATE YEAR POINT OF & 1� O COM VEH 0 IZI 1 0
I— FIRST CONTACT 4 7 '`''•' •ir Yes,See Sidebar U1 0
Z EA87631 IL 2024 rsAii
. ID VIN INSURANCE CO. EXPIRED
0 5J6RM3H53CL035755 Westfield National Insura 0 Y ®N U21.1 m
m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Y SABO.SARA, L. WNP5145270 1
o HOSPITAL(TAKEN TO) INCIDENT IF O'Y' WNER STREET.CITY,STATE,ZIP PHONE NUMBER r
L RESPONDER 1065 VAN ST. ELGIN - IL.60123 (847)507-4823 VEHU G1
m ❑DRIVER 0 PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 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 11 12 Xi
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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
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 CI SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value UI 0 -
POINT OFto
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_11 6 1_S CIOMes,See Sidebar
REAR ❑ ❑ C
1-
CA
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF7.1
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 <
RESPDYOIDNR Ut I
(UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 1 1 1 10,20 ,2024 01 49 ❑pM in a Work Zone? El DIRP co
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 I
1 0
T 2 ❑ 10,20 ,2024 ❑PM ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
a ARREST NAME 10/20/2024 ❑PM SLMT
o U 1 ❑ CITATIONS ISSUEDPENDING ROAD CLEARANCE TIME ❑Utility
n 0 0 SECTION CITATION NO. 8 AM3O
o N
2 ❑ ARREST NAME I / ppl 0 Unknown work zone type U1
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ ®AM Workers present? El Y
1517-Le Cates. Brittany 1 oo 360-Yucaitis 11 , 15,2024 09 00 0 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, . 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. ` ' ' 1 ', ' 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 • : - J I I + i } - t transporting employees in the course of their employment(example.employee 71
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) M
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CARRIER NAME Z
' .. ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate El Intrastate <
. . . ❑ Not in Comm./Govt. El Not in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
, Source of above z
. GVVVR/GCWR —I
m
❑ <10,000 0 10,000-26,000 0 >26,000
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
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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 U COLOR TRAILER LENGTH(S)1 ft 2 't z
Blue-Dark
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE Xi DISABLING DAMAGE DAMAGE EXTENT- 4 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