HomeMy WebLinkAbout2024-00069025 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 111100 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03606511
u, 9 u21 1 1 1 u199 U2 1 U199 U2 1 U,99 U2 1 1 9 U1 99 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202412024-00069025 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1100 S RANDALL RD Elgin04:00
® ❑ RELATED ❑y ®N 10 26 2024 DAM ❑YES ®NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
COUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FR0'1T TOWED U1 0
Unknown. UNK.0. Unknown Unknown 00-NONE „ 12 , DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_i L s 4 COM VEH ❑ j$J 1
I... FIRST
9 FIRST CONTACT 99 7_; __5 *IIVes.See&debar U1 0
Z UNK REAR
' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNK UNK ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNK 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 GG)
mo DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
yr 11-I 12 -1 ❑ ! l 2 C
Ti 13-UNDER CARRIAGE 10( 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
NJ -TOP 3 9 X
a ❑Y N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value
POINT OF 8 4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 1�'`_ COM VEH ❑ ® CO
F,,, FIRST CONTACT 7 O7 __, _5 •IT Yes.See Sidebar
CT91683 IL 2025 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4S4WMARD0K3407811 Bristol West El V ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Sagadraca. Nina G01 3971423 01 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 10,29 l2024 05 20 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 20
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 99
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! - ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 2
z
-a, ARREST NAME / / El PM '
S' N ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
10
T ❑ AM
7 ❑PM ❑Unknown work zone type U1
2 ARREST NAME 1 / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 1 O
559-Maldonado. Daniela sot , ! ❑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 ----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 truck trailer -<
` ` --I -' r INDICATE NORTH combination):or —I
Not To Scale I e 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or co
_^/ '�! //// } F 1. •4. ctc or designatedatiotx transport between 9 and 15 passengers,s,including the dryer. U)
for direct compensation(example:large van used for specific purpose):or 0
L L____a____� �� _ t i i. t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
'D
I I I I t placarding(example:placards will be displayed on the vehicle). XI
I. /i
CARRIER NAME Z
ADDRESS 0
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
73
Source of above Z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No El Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Bronze
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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE