HomeMy WebLinkAbout2024-00069026 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
IIIIII 11
II fff11111111110II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a637.999
u, 1 U21 2 4 1 U, 2 U2 1 U, 1 u2 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 91,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-00069026 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N LIBERTY ST El In 04:59
® ❑ RELATED ®Y 0 N 10 29 2024 ❑AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W ENTERPRISE ST COUNTY PROPERTY :IY ® N DOORING ❑y #OF MOTOR El SLOW 15 '
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑uuv 0!Cy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
r tf
0 5 /
yr 13-UNDER CARRIAGE 10.I I: 2 FIRE 0
NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTHER TAL(ALL) DISTRACTED 0 0U2 00 M657 M 3 4 ❑Y El El UNK VEH. 0 AT CRASH 0 99-UUNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii_6 1, 4 COM VEH 0 jg! 1
Z ELGIN IL 60120 C 1 0 CB99777 IL FIRST CONTACT 1 T_; __s ves.See Sidebar Ut 0
REAR
TELEPHONE
IL 1 NXAE09B4SZ297226 None ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same None 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 5 0 Acura M DX 2017 00-NONE O,' t2 "_, DUE TO CRASH ❑ 2 x
o _y Yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7� -6 •If Yes.See Sidebar
H ELGIN IL 60120 0 1 0 R760610 IL I C
0
M
IL SFRYD4H5XHB025837 State Farm ❑Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2094350-STP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
O N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
2 3 10 /
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 10,29 /2024 04 59 ®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
o"
2 ❑ 2 28 / / ❑PM- ❑Construction
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-, 1 ® 11 4 ARREST NAME Anongsack.Thienthong 3-707 432-919 / / El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
0 AM
t 2 ❑ ARREST NAME 10/29 /2024 05 15 0 PM ❑Unknown work zone type U1 30
2 2 3 ID El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1546-Ignacio. Patricia 202 334-Fries 11 /26,2024 09 00 ❑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
r CD - combination):or more than pound (example:truck or truckrtrarler 1. Has a weight rating10 000 5 i -<
INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 C
I - } r n LI
(example:shuttle or charter bis):or passengers including the driver
411
Nof To Scale
J 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I
A O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or
L L.___a__ �•oR ) 4---- •q. Is used or designated to transport between 9 and l ssen rs,including the driver,
C
1--- 4101 } } } for direct compensation(example:large van used fors specific purpose):or O
- - - Unit -OW2
71
L L--_-a-___. LT
t 5 Is any veh de used to transport any hazardous matey al(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
21
D
n.zueab CARRIER NAME Z
. . . . 1 1ADDRESS 6)
v)
u C)
CITY/STATE/ZIP g
2 I•I MOTOR CARR.ID 0 Interstate 0 Intrastate 5
�ILI -
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i- --- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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? A
❑ Yes II El Unknown C
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Beige Black
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 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE