HomeMy WebLinkAbout2024-00068009 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIII lull
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602256
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW 1
Elgin Police Department ONE PERSON'S Ed$501-$1.500 ®ON SCENE 2
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ElB Injury and/or Tow Due To Crash YR 202412024-00068009 VENT '
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
CORRON RD ® ❑
Elgin RELATED ®Y ❑N 10 25 2024 0129 ®AM ❑YES ®No u1 • ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW CI)
E15 0/MI N E 0 W Bowes Rd 'WITH VEHICLES INVLD El STOPPED U2 —1
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LN5 ' 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FRONT TOWED U,
NAME(LAST,FIRST,M) mo day yr 121 O
, E. General Motor�errain 2024 00-NONE 11 DUE TO CRASH 0 21
,3-UNDERCARRIAGE io) , 2 FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 m
3640 TOURNAMENT DR M ❑Y ❑SYSNEM❑UNK VEH. 2 AT CRASHD 2 15-OTHER
99-UNKNOWN 9 76-TOP 3 ,Distraction Value ALGN 2
CITY PLATE NO. STATE YEAR POINT OF & {I 6 ii 4 COM VEH 0 El 1 0
A
3GKALPEG2RL144812 Unknown ❑Y ❑N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn
AVIS Budget Rental Unknown 2
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r
o RESPONDERN 2668 E MAIN ST.St Charles. IL.60175 (630)587-1945 VEHU
0 DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
rU / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 Xi
C
c 13-UNDER CARRIAGE 10 I I I 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED C�
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPCA
Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •DetractionValue U1 3 -
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POINT OFto
N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 6 I_5 C•IOMes 3eeSideba0 ❑ C
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REAR
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID V1N INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF
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
YO0 NR U, 2
(UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
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/ / - '#OCCS >
/ / U1 1 D
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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 0 1 3 10/25 /2024 01 30 ❑pM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)T 2 I� 34 3 28 11
! / 0 PM ❑Construction *
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N 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
ARREST NAME / / ❑PM SLMT
o U 1 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
p N AM 45
2 ❑ ARREST NAME 10/25 /2024 01 29 El RA0 Unknown work zone type Ut
Fo T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME present? El
469-Taylor,Jonathan 801 - / / 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.
r 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. Z
r- -r--- 4 , 4 r r r r r , , , , . r
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' r • ; i ; i- r r , , i INDICATE NORTH combination).or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n
S
; 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 ,3
transporter-usually a van type vehicle or passenger car).or w
' i 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
•
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP O
, ,
. - MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not m Comm./Govt. ElNot rn Comm./Other Q
C
r-----.-----, i r r r r r•---, r - DO ILCC NO. m
U N XI
, Source of above 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? O
❑ Yes No ❑ Unknown C
Was a driver/vehicle Examination Report Form completed? 1:,
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
z
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Silver
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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