HomeMy WebLinkAbout2024-00071087 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IIII Mil 01100 00 110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003619331
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00071087 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ❑Y ®N 11 08 2024 ®AM ❑YES ElPRIVATE NO U1
JAY ST Elgin mo /day/yr 08:46 ❑PM FLOW CONDITION Ill
I 0 ®!MI N OE S W StCharles St COUNTY PROPERTY 0 Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(8:DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
yr 13-UNDER CARRIAGE f�.{ I!. 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH ❑ Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[a !i,_ 1 00
~ 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N4y 0 NOV 0 DV CIRCLE NUMBER(S) U1
1 9 6 6 Chevrolet Bolt 2023 Do-NONE ,�_O' t2 "_, DUE TO CRASH ❑ C 273
O Yr 13-UNDER CARRIAGE ( 2 FIRE ID El U2 C
c
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 9 X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il 6 11:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 1 O Y -5 •IfYes.See Sidebar
Z ELGIN IL 60120 0 1 FP200827 IL 2025 REAR 0 N
IL D 1G1FX6S07P4139088 unknown ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Avis unknown BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 11 ,08 /2024 08 46 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 18 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / ❑PM '
o u ® 11 3 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
t 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 30
225 Wolek•Thomas 275-Engelke / El 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
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 i. <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_, , < <--_-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 ...._-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE