HomeMy WebLinkAbout2024-00070278 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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II 11111111 11
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV 03M13545
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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 El$501-$1.500 ®ON SCENE 8
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 202412024-00070278 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 11 04 2024 DAM YES ®NO U1 —<
HOPPS RD Elgin02:05
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Kell Geor e.T. 1 2 /
yr
13-UNDERCARRIAGE fal 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 O m
M 2 8 ❑Y ®SYSNEM IN DUNK VEH. O AT CRASH ENGAGED O 99-UUTHER
NKNOWN 9 16-TOP�3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 1,4 COM VEH ❑ j$J 1 0
F. FIRST CONTACT 1 7_;—__;_-6 *Ilves.See Sidebar U1
Z Orland Park IL 60467 0 1 0 AM28559 IL 2025 REAR
TELEPHONE
IL D 0 5J6RW2H87HL048238 State Farm ❑v Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Walsh-Kelly, Marie 1164384-SFP-13 2 m
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv
2 0 0 3 Acura TLX 2025 00-NONE 11_"1 Qi O DUE TO CRASH rg ❑ 2 x
0Yr 13-UNDER CARRIAGE 10( 2 FIRE 0 ® U2 C
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F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y 181 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 Il, COM VEH 0 ® U1 CO
FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar
= ELGINREAR C
M IL 60123 B 1 0 DU53424 IL 2024
IL D 0 19U U B6F5XSA000006 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 2247065-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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
N 1 ® 11 4 11 ,41 ,024 02 05 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 2 99 11,41 /024 02 05 mi PM ❑Construction *
R 3 0 lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Kelly.George.T. 11-902 1538000019 11,41 r024 02 13 ®PM SLMT
1 ® 11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
PENDING
o N
t 2 ElARREST NAME 1 1 r 4) 1024 02 52 ®PM ElUnknown work zone type U1 50
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME CIAM Workers present? ❑Y 50
1538-Estrada, Leticia 700 334-Fries 12 , 3! ,024 01 30 ®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
I I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }--__r-_--; INDICATE NORTH combination):or
�
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N I I - } (example:shuttle or charter bus):or
RandsL T,
Rd I I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; o` - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
Q- for direct compensation(example:large van used fors specific purose):or
L L____a____� �'•� _ t . i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
51ti_ H.F.P.Rd
- CARRIER NAME Z
r r -1- -: 7 il LADDRESS
rn
CITY/STATE/ZIP n
II i.- i. i. i. 4. MOTOR CARR.ID 0 Interstate ❑ 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
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LOCAL USE ONLY TRAILER VIN 2 m
v
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. Z
Gray White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE