HomeMy WebLinkAbout2024-00070623 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
01101100 II 0 0011 lI1I II1100
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003615332'
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00070623 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑ ❑Y ®N CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
®AM U1
RELATED 11 06 2024
N STATE ST Elgin mo /day/yr 06:04 ❑ ❑YES ®NO
PRIVATEPM FLOW CONDITION M
once,MI N E O W North Schiller Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 6 Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS O
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 0
FOR DAMAGED AREA(S) FRO4T TOWED U1 Q
NAME(LAST,FIRST,M) Harris. Eric.G. 0 mo 4 / 1 9 9 0 Acura TL 2006 00-NONE „ Oi_1 DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 !3 U2 04 r<n
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 76•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Ir Yes.See Sidebar U1
Z EW81586 IL 2025 Ismi
TELEPHONE
IL D 0 19UUA6624A024994 First Chicago ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same PAL101518000 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 i v ❑DV
/1 9 9 1 Chevrolet Silverado 1972 00-NONE ,�_"j Q�-_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10( 1 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistractIon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 .5 •It Yes.See SidebarC
H ELGIN IL 60123 0 1 0 179511F IL 2025 I 0 Si)
M
IL A 7 American Family ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 10 =
Same 410306641774 BAc E
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)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
3 3 01 /
U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 1 11 ,06 ,2024 06 04 ®❑PM in a Work Zone? ❑N DIRP co
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
0 2 0 03 28 ! , ❑PM ❑Construction *
" 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Harris. Eric.G. 11-601 S1537000028 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM U1 35
t 2 ❑ ARREST NAME 1 1!06 ,2024 06 10 [M PM ®Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1537-Mapp.Teddron 500 404-Duffy 12 !03,2024 09 00 ❑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.
. 0
r ----r••--, I ! A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Nratingmore than pounds(example:truck or truckrtrarler
_I
combination):or
1. Has a weight 10,000
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver Z
_ (example:shuttle or charter bus):or
— — — — , r 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
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esg pa g pe
} } } transporting employees in the course of their employment(example:employee
CO
< ...I.
or X
9�Itler , I I.
transporter sed or usually designated to transport between 9 and 15 passengers,isen rs,including the driver. to
} } for direct compenation(example:large van used for specific purpose):or O
L L____a..... 1 I - t i i i. i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). Dm
-1
CARRIER NAME Z
'' NTstate o
It ADDRESS
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o
CITY/STATE/ZIP
:- ., d
- MOTOR CARR.ID 0 Interstate 0 Intrastate
r Not To Scale .I _ 0 Not in Comm./Govt. 0 Not in Comm./Other 00
�"--- ----4, - USDOT NO. ILCC NO. m
m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
co
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
White
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE