HomeMy WebLinkAbout2024-00069345 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003637.42
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00069345 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® ❑ RELATED ❑Y ®N 10 31 2024 ®AM ❑YES ®
PRIVATE NO U1
ST CHARLES ST Elgin mo /day/yr 06:53 ❑PM FLOW CONDITION m
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010(D!MI N E O W Hammond Ave COUNTY PROPERTY ElY ® N DOORING Ely #OF MOTOR ElSLOW 15 Co
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Unknown.0. Unknown Unknown 00-NONE ,, • 12 DUE TOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I ! FIRE
O ❑ tE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 115-OTHER
4-TOTAL(ALL) 10 EN E
DISTRACTED 0 0U2 4 MUNKNOWN 9 9 ❑Y El CO LINK VEH. 9 AT CRASH D 9 99-UNKNOWN 9 16•TOP() *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s FIRST CONTACT 2 7_;iL 6 ii,_- COM VEH 0 Ea 1
I- 0 9 5 *II Yes.See Sidebar Ut 0
Z UNKNOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 6 lii
Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same NIA 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ❑ N 99
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 NOV ❑DV
/1 9 yf 0FROM TOWED
Trax 2019 Do-NONE 11_. 0
12 "_1 DUE TO CRASH ❑ 2
0
®13-UNDER CARRIAGE I 2 FIRE ID ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 0916•TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 O NT OF O`Ij 6 L`_6 CIO es See SH idebar❑ ® UtCO
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F= E LG I N IL 60120 0 1 BA51389 IL REAR
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IL 3GNCJLSB6KL167731 Kemper ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 8 x
Same 12A0001436956 BAC $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CO 11 9 10,31 /2024 06 53 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 18 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING ( / ❑pM, ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME ( / ID PM '
oN 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 ❑ ARREST NAMEAM
( 7 ( / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1529 Audi red.Jonathan 401 404 Duffy / / ❑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
t ADDITIONAL UNITS FORMS.
r ----r•---, , A A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver and:
} - } (example:shuttle or charter bus):or X
J THAMMOND?AVE 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
I- --I-- --J.
- } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
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L L.___a.. - I. } 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
} for direct compensation(example:large van used for specific purpose):or 0
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L I. } L 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME Z
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I CITY/STATE/ZIP 0
- MOTOR CARR.ID 0 Interstate El Intrastate
1 I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-1 I I USDOT NO. ILCC NO. m
73
Source of above z
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. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
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IDOT PERMIT NO. WIDELOAD'/ ❑Yes 0 No 2
TRAILER VIN 1 m
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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
Red
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