HomeMy WebLinkAbout2024-00070625 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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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 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00070625 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
® ❑ RELATED ❑Y ®N 11 06 2024 ®AM ❑YES El NO U1 -<
168 US ROUTE 20 HWY Elgin PRIVATE mo /day/yr 06:09 ❑PM FLOW CONDITION m
�O ICJ ® COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
!MI N E SState St WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) •FROt4r TOWED U1 Q
E eh. Liban. R. 1 0
yr 13-UNDER CARRIAGE �a:, 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iII a ii,4 COM VEH 0 j$J 1 00
~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 6 7_;LQ__5 *Ir Yes.See Sidebar U1
Z DF41891 IL 2025 E
TELEPHONE
IL D 2HKRW6H38KH2O8026 State Farm ®Y ❑N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire GULAID CONSULTING EN K348658C0913 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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Ei{ DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMv 0 NCv ❑Dv
1 9 yf 9 Ford F550 2022 00-NONE i1_"j Q�,-_, DUE TO CRASH 0 ® 14 x
0 13-UNDER CARRIAGE 10( I FIRE ❑ El U2 C
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M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 i1�i 4 COM VEH D ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B _5 •If Yes.See Sidebar
ZSycamore IL 60178 0 1 0 208968H IL 2025 I 0 C
D
IL A 7 1 FDOX5HTXNED79361 Westfield ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
MCCANN INDUSTRIES IN CMM342634H BAC
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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)
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 ,61 ,024 06 09 ®❑PM in a Work Zone? ®N DIRP co
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ®AM If YES check one below: U1 3 0
T 2 0 11 1
v 11,61 l024 06 10 ❑PM ❑Construction >F
" 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
®AM ❑Maintenance U2
- u a ARREST NAME 1 1/61 ,024 06 16 ❑PM '
,
1 ® 0 Utility
1 1 1 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING SLMT
o U, 55
r 2 0 ARREST NAME 1 1 r 61 1024 07 30 MAM PM El Unknown work zone type
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 55
298-Lopez, Mirko 701 272-Bajak 12 , 91 ,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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -;-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination)or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' , } (example:shuttle or charter bus):or
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3. Is
L L.___A_. 1 ..._.... J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or 03
I- <.__-a-_-_-I , l• I- I- <--_-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 L___-a____.: L L L i.___-..i.____� L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
i.
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Red
u 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE