HomeMy WebLinkAbout2024-00069391 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
01101100 II 110010100100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003607125
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00069391 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1325 BLUFF CITY BLVD El In11:38
® ❑ RELATED 0 Y ®N 10 31 2024 ®AM ❑YES ®NO U1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 6 (n
❑ FT!MI N E S W Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg)DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRO'1T TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 ! 2 FIRE ❑ IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 m
9 IN ENGAGED
9 ❑Y ESYlM COUNK VEH. 9 AT CRASH 9 ®15-OTHER UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i L B 4 COM VEH 0 j$J 1
H 0 9 FIRST CONTACT 99 7_; __5 * ryes,See Sidebar U1 0
ZUNKNOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 111
UNKNOWN Unknown ❑Y ❑N U2 I'
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same Unknown 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 9 99 G0)
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
yr 13-UNDER CARRIAGE 10 12
I ,, E FIRE ❑ ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9
a ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��'._ COM VEH El ❑ CO
FIRST CONTACT 1 Y _, _5 •• •It Yes,See Sidebar
H P770392 I L 2024 I:EaR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4V4ND3JJOYN236928 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 99 =
Malyutyk.Serhiy 988437032 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 LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 10,31 l2024 11 38 ®❑pm AM in a Work Zone? ®N DIRP D
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1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1
—a, ARREST NAME / / ❑PM
o N I ® 11 5 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utili 15
ty
SLMT
t 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ID Workers present? 0 Y 15
1529 Audi red.Jonathan 401 404 Duffy r / ❑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 ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (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 w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L i t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
-I
CARRIER NAME Z
ADDRESS 0
V)
CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
------r-- - % % % usDOT NO. 1300494 ILCC NO. 138398
x
Source of above Z
. own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash? A
❑ Yes II ❑No 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 ®No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
11
TRAILER 1 ® 0 0 z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. Z
Black Purple
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES 2
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. 2 CARGO BODY TYPE 9 LOAD TYPE 5