HomeMy WebLinkAbout2024-00068028 (3) ILLINOIS TRAFFIC CRASH REPORT Sheet 5 of 6 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 El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON
VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00068028 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH '11
BIG TIMBER RD ❑Elgin RELATED ®Y ❑N 10 25 2024 07:01 ®AM ❑YES ®NO U1 .(
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
FT/MI N E S W N MCLEAN
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
❑ORNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv ❑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 ❑ ❑
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 KNO & {I 4 Distraction
Value ALGN
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CITY PLATE NO. STATE YEAR it� COM ER 0 0 0
FIRST CONTACT 7__.REnR 5 "If Yes,See Sidebar U1 0
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. ID VIN INSURANCE CO. EXPIRED
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m / / FOR DAMAGED AREA(S) FRONT TOWED
fi ' 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 C
a 13-UNDER CARRIAGE 10 j 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ SPDR C0
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
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_5 C•IOMe6 VEH
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER C
D YOEl N Ut I
(UNIT) (SEAT) (DOBi (SEX) (SAFT) (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 Did crash occur ❑Y U2 Z
N 1 - El - City of Elgin AXIS VIDEO CAMERA 10/25 /2024 07 01 0PM inaWorkZone? ®N DIRP CO
I PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 0
/iiiT 2 ❑ 150 DEXTER CT ELGIN IL 60120
! ( PM El Construction *
-1N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
•
ARREST NAME / / ❑PM SLMT
o U 1 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N 8 Al:
2 0 ARREST NAME / I A ❑Unknown work zone type U1
Fo T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 244-Blomberg. Michael 502 272-Bajak 11 /26/2024 01 30 0 PM Workers present? ®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
• ADDITIONAL UNITS FORMS
' } A CMV is defined as any motor vehicle used to transport passengers or property and
, . r r r r , , , , . r0 .
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. ` ' ' 1 ', ' I. ` 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 • : - -, I + i } - t transporting employees in the course of their employment(example.employee X1
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
11
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
•
CARRIER NAME Z
' ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate El Intrastate <
• . ❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
•• , • Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
z
GVWR/GCWR —I
❑ <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 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
z
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 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't z
• TOTAL VEHICLE LENGTH ft. NO.OF AXLES
U TOWED ❑ 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