HomeMy WebLinkAbout2024-00069507 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100
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DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X003611443
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2024I 2024-00069507 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mS STATE ST Elgin07:51
® ❑ RELATED ®Y 0 N 10 31 2024 ❑AM ❑YES ®NO U1
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W MIDDLE RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 co
❑ Kane HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT�TOWED U1 I�
MC KINNEY. DEUCE.O. 1 0 /
yr 13-UNDER CARRIAGE NI
1U 1 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 m
F 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 j$J 1 0
F.
ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar Ut
Z CF79117 IL 2025 REAR
TELEPHONE
IL D 0 1GYKNDRS7HZ324926 PROGRESSIVE ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 986895144 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
p;rg- DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMv 0 K V ❑DV
!1 9 yf 0 Audi Q5 2016 00-NONE 'o,I t2 c 2 FIRE DOE OCRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•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 5 1 6 --4 COM VEH ❑ ® ut W
FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.See Sidebar C
m SOUTH ELGIN Z I L 60177 0 1 0 W 330186 I L 2025 aR 0 N
M
IL D 0 WA1 L2FP6GA098435 STATE FARM ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 0586878SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 04 /
U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 10,31 /2024 07 51 ®AM 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 C)
v 2 10 28 10,31 l2024 07 51 ®PM ❑Construction
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
-a, ARREST NAME MC KINNEY. DEUCE.O. 11-601 S1519-000212 10!31 ,2024 08 00 ®PM SLMT
1 ® 11 1 0 Utility
❑CITATIONS ISSUED PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME
t 2 El ARREST NAME 10)31 12024 08 45 ®PM El Unknown work zone type 0 AM U1 35
, T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 35
1519-Bae2 a.Guadalupe 701 r 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 truck trailer
r INDICATE NORTH A
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driverC
} - i. e. r r (example:shuttle or charter bus):or 0
. N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
I- I- _A----i STSTATETST
- i } } } transporting employees in the course of their employment(example:employee P3
_Not To Scab_f 1 transporter-usually a van type vehicle or passenger car):or COz
L }-----}----; N ' } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)
1 I for direct compensation(example:large van used for specific purpose):or
—
L L___-a... - t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M
, placarding(example:placards will be displayed on the vehicle). XI
M E t
— — — — 21
l CARRIER NAME Z
ti - ADDRESS O
n
r CITY/STATE/ZIP g
I MOTOR CARR.ID 0 Interstate 0 Intrastate 5
r ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
�I. --- --1 - USDOT NO. ILCC NO. C
m
73
Source of above Z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. 71
73
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Jims/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE