Loading...
HomeMy WebLinkAbout2024-00070552 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil l III H IIIl 11111111 1100001111110111111 HID DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo0a62-D r u1 1 U2 1 1 1 U1 1 U2 U1 1 U2 U1 1 U2 4 4 U1 1 U2 *P 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑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 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00070552 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N STATE ST Elgin06:12 ® ❑ RELATED ❑Y ®N 11 05 2024 DAM ❑YES ®NO U1 —< _ _ PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W J U DSON DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 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) FROf tf TOWED U1 Q Clark.Jeffre L. 0 8 / yr 13-UNDER CARRIAGE ©(O O FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O DISTRACTED 0 Ea U2 m M 2 4 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 t6•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ;i�s 4 COIN VEH El Ea 1 O F. FIRST CONTACT 12 7 ;•-_,_-5 *If Yes.See Sidebar U, Z SOUTH ELGIN IL 60177 0 1 0 AU36812 IL 2025 RFtiR TELEPHONE IL D 0 5N PE34AB4J H684141 Country Financial ❑Y Igl N U2 Mr- Ill 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Genge. Elizabeth.A. P010726033 2 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ❑ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 yr 12 _ 71 o 13-UNDER CARRIAGE ��.i :., FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+':=5 C•IO e1sVEH See •Sidebar❑ 0 C CO I� pEAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / / ##occs > Pj 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 15 1 Department of Natural Resources Deer 11 ,51 ,024 06 11 ®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 ,, ;, t 2 ❑ 1 NATURAL RESOURCES WA'pringfieldL 62702 21 99 ! , ❑PM ❑Construction * Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 a ARREST NAME / / ❑PM ' o2. u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 t 2 El ARREST NAME 1 1!5/ 1024 06 11 ®PM El Unknown work zone type U1 AM 45 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ ❑AM Workers present? 0 1500-Chew. Marie 501 334-Fries , ❑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••--, , L ; 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 truckrtrailer -< i- }____r____1 combination):or INDICATE NORTH p1 o,...„......,„c„.......u.I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver 0 (example:shuttle or charter bus):or n r r X 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O - ------I----; +.+w�,u. - transportig employees in the course of their employment(example:employee X - Not To Scale I I transporter-usually a van type vehicle or passenger car):or w -- - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, u«, I - i - for direct compensation(example:large van used for specific purpose):or O - } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI —I i. - CARRIER NAME Z ADDRESS T. CITY/STATE/ZIP n g - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 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 . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI XI Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE