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HomeMy WebLinkAbout2024-00069279 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 II 111111110 11000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003647.50 u, 1 U21 1 1 1 U1 4 U2 1 U1 1 U2 1 U1 1 U2 1 4 11 U, 1 u2 1 *P 0 1 1 9 INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00069279 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n RT20 WB El In 06:36 ® ❑ RELATED ❑Y ®N 10 30 2024 DAM ❑YES El NO U1 —< g PRIVATE mo !day!yr ®PM FLOW CONDITION m 1 O !MI N E s w West Liberty St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n ® O Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 ! yr 13-UNDER CARRIAGE ©I ! 2FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SY4 ❑Y ONM DUNK VEH. O AT CRASH IN 0 99-UNKNOWN 9 16-TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S 4 COM VEH 0 j$J 1 O ~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 12 7 . _5 *II Yes.See Sidebar U1 Z3889651 IL 2015 E TELEPHONE IL 0 1 HGES16532L061449 Allstate Insurance ❑Y I l N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 811948079 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y El 2 0 ��, g DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NIAV 0 NOV 0 DV !1 9$5 Chevrolet Cruze 2017 00-NONE 'o,I t2 c 2 DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 POINT OF 8 i 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QIOS •It Yes,See Sidebar C Iowa IA 52404 0 1 0 OCT663 IA 2025aR0 Z M IA C 0 1 G1 BE5SM6H7175579 Statefarm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 15C2K6204 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 11 1 10,30 /2024 06 36 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 03 99 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING • + ! - ❑PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a, ARREST NAME / / El PM ' o U 1 El1 1 10 • ❑UtilityCITATIONS ISSUED PENDINGSLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME AM t 2 ❑ 11 1 ARREST NAME 10/30 l2024 06 40 0 PM ❑Unknown work zone type U1 45 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ — ❑AM Workers present? 0 Y 45 1500-Chew. Marie 401 / ❑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 truckrtrailer -< c ` -' -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C A - (example:shuttle or charter bus):or X L A I N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O ll - . - . transporting employees In the course of their employment(example:employee i. `�----:----' Not To Salle j - } } } •transporter. sed or des gnated to transport betweelly a van type vehicle or n 9 and 15 passengers,including the driver,enger car):or X - ------ ----- for direct compensation(example:large van used fors specific purose):or i. i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a I t placarding(example:placards will be displayed on the vehicle). m XI `_ D CARRIER NAME Z Z —.rMr9-1.1n12 —unr1— — O ADDRESS R0 1720 n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn XI Source of above 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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