HomeMy WebLinkAbout2024-00067809 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIII lull
111111111111111111111111111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602236'
u, 1 U2 1 1 1 Ui 1 U2 U, 1 U2 Ut 1 U2 4 4 Ut 1 U2 *P 0119*
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 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067809 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
E RT20 E/B HWY ❑Elgin RELATED ❑Y coN 10 24 2024 03:47 ®AM ❑YES ®No u1 • ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
1 'COUNTY PROPERTY El ®N DOORING ❑'' #OF MOTOR ❑SLOW CI)
® FT 0 N OE S W Lavoie Ave 'WITH VEHICLES INVLD El STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' O
tg DRIVER 0 PARKED 0 ERNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FRONT TOWED U,
NAME(LAST,FIRST,M) , H. Kia Motors CoItos O
2023 00-NONE �� DUE TO CRASH ❑
mo day yr O
,3-UNDERCARRIAGE 10 2 FIRE 0
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
825 I N D IAN WELLS CI R F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8 j 6 4 COM VEH 0 ® 1 0
A ~
KNDEUACAAOP740565 Allstate El ®N U2 49 . m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Same 932590718 1
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ❑N 2 G)
m 0 DRIVER ❑ PARKED 0 CRNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 WV ❑NCv 0 ov 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 1t 12 C
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 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value U1 0 -
—
POINT OF
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II a I_5 COM
e63eeSideba❑ ❑ C
H R • C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2CA
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 <
RESPONDER
YDI NR U, 2
(UNIT( (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTHI PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
M
/ / - #OCCS ' D
/ / U1 1 D
/ I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z
1 N 1 ® 15 1 State of Illinois Deer 10,24 ,2024 03 47 ❑pM in a Work Zone? ®N DIRP co
I PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
T 2 0 150 DEXTER CT ELGIN IL 60120 21 99
! r 0 PM El Construction *
or t 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o u 1 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N 8 AM 45
2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut
% T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 El ❑AM Workers present? El1520-Gutierrez.Jovani 401 - r / 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
I I 0 ADDITIONAL UNITS FORMS
.
' } 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 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 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 r----, i - DO ILCC NO. m
U N XI
, Source of above Z
own tank)? ❑ Yes ❑ No ❑ Unknowr
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
0
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
BlackEn
-
U 1 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