HomeMy WebLinkAbout2024-00067771 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111 III Olfi
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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 SCENEEl NOT ON • 22
VEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067771 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH gg 71
BELLEVUE AVE ❑Elgin RELATED ❑Y co" 10 23 2024 10:12 ❑AM ❑YES ®No U1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W SLADE AVE 'COUNTY PROPERTY 23 Y ❑N DOORING ❑Y #OF MOTOR 0 SLOW CI)
❑ 'WITH VEHICLES INVLD ElSTOPPED U2 —I
ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN (23Y ❑ N PEDALCYCUST®N ® FREE FLOW # LNS 0
DI DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH p21
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE �0 1 2 FIRE ❑ 1 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 El U2 m
9 16-TOP 3
r ❑Y ❑N ❑UNK VEH. AT CRASH ®INT UNKNOWN
OF 8 il� 4 COM VIER ion�� 0 ® ALGN
CITY PLATE NO. STATE YEAR } e 1
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ID VIN INSURANCE CO. EXPIRED
o UNK ❑Y ❑N U2 m
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Ya Same UNK 1 r r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU X
L ❑Y ❑" 99 0
m 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR Ut
CIRCLE NUMBER(S) Y N m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi i DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 X
a 13-UNDER CARRIAGE 101 j s FIRE ❑ ❑ 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
❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value Ut 9
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 CIOMe6 VEH
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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
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPElYOElNR U, _
(UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) C)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
1 N 1 23 43 g City of Elgin Damage Stop Sign 10,23 ,2024 10 12 ®PM in a Work Zone? ®N DIRP CO
PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 8 0
T 2 0 150 DEXTER CT ELGIN IL 60120 99 99
! r 0 PM El Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / 0 PM SLMT
o U 1 0 0 Utility
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
2 N8 AM 25
2 0 ARREST NAME r / ppl ❑Unknown work zone type U1
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 0 ❑AM Workers present? ❑
1519-Bae2a.Guadalupe 102 - r / 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.
IF 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
: l : l : 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' •_ I ', ! i- ._ ' ' '. ', ' f ` 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
' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers 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 O
• . - MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not in Comm./Govt. El Not in Comm./Other Q
m
r-----.-----, r r r r ,-•---, - DO ILCC NO. m
U N XI
•
, Source of above Z
•
.
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No
73
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 g
Did Carrier Safety Regulations(MCS)violation contribute to the crash% A
❑ Yes No ❑ Unknown 0
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
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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