HomeMy WebLinkAbout2024-00067865 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets II III III III I
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
0 NOT ON
VEHICLE/PROPERTY ElOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067865 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH '11
KATHLEEN DR ❑Elgin RELATED ❑Y coN 10 24 2024 11.36 ®AM ❑YES ®NO U1 ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW CI)
❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0
❑DRNER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGED AREA(S) FRONT_ TOWED U1 0
00-NONE 11 12 1 DUE TO CRASH ID E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE 0 0
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 0 U2 m
9 16-TOP 3
r ❑Y ❑N ❑UNK VEH. AT CRASH POINT UNKNOWN
Distraction
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CITY PLATE NO. STATE YEAR it� COM ER 0 0 n
FIRST CONTACT 7__. ___5 "IrYes,See Sidebar U1 0
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. ID VIN INSURANCE CO. EXPIRED
o ❑Y N U2 m RSUR m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER m
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o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER VEHU D
o ❑Y ❑N 0m ❑DRNER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
11, 13-UNDER CARRIAGE 101 i 3 FIRE ❑ ❑ U2 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 ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe6 VEH
SeeSideba❑ 0 C
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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 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER C
DYOIDN Ut I
(UNITE (SEAT) ;DOB) (SEX) ISART) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0
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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 El10/24 /2024 11 36 ❑pM in a Work Zone? ElN DIRP CO
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 0 T 2 ❑
t
! , PM ❑Construction >F
cs 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
•
ARREST NAME / / 0 PM SLMT
,- U 1 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N 8 AM
2 0 ARREST NAME / I ptil El Unknown work zone type U1
T OFFICER ID SIGNATURE BEAT/DIST •
SUPERVISOR ID. COURT DATE TIMEEl 2 3 ❑ 244-Blomberg. Michael 602 272-Bajak 11 /26,2024 01 30 0 PM Am Workers present? ®Y
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
. 0
' 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 'r 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 '. ' 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
' 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
X.
. `
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP 2
, ,
MOTOR CARR ID ❑ Interstate ElIntrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r ,-•---, r - DO ILCC NO. m
U N XI
•
, • Source of above Z
•
. GVVVR/GCWR
❑ <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
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 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
TRAILER 2 ❑ ❑ ❑ 0
U COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
• - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
UTOWED ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO
DUE 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