HomeMy WebLinkAbout2024-00070663 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a624965
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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 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00070863 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® ❑ RELATED ®Y 0 N 11 07 2024 ®AM D YES ®NO U1
W HIGHLAND AVE Elgin05:37
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N CRYSTAL AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 21 PEDAL ❑EDUCE ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRO fir TOWED U1 0
Unknown,O. Unknown Unknown 00-NONE „ 12 , OUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 191 !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0 m
SYSTEM IN ENGAGED OTHER 9 16.TOP 3
M 5 3 ❑Y ❑N ❑UNK VEH. AT CRASH 9 UNKNOWN Distraction Value ALGN 2
$ 4 COM VEH ❑ ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _.I[S !i,_ 1 00
~ 0 9 0 FIRST CONTACT 15 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE
IL Other K6F0002480 Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 47 1 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
.o Other ❑Y El 3 99 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
!1 9 y yf 8 Ford F150 2003 00-NONE 11_"j Q�,-_, DUE TO CRASH ❑ El 2 x
0 13-UNDER CARRIAGE 10( l FIRE ❑ ® U2 C
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M 2 4 ❑Y El ❑
SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
N UNK VEH. AT CRASH 99-UNKNOWN r.
`Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il 6 I1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 , -9 •IfYes.See Sidebar
Z ELGIN IL 60123 0 1 0 1841382B IL I:EaR C
0 Si)
IL D 1 FTRX18LX3NB73698 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same 2499144SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 3 U1 =
KNIT) (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 0 Y U2 Z
N 1 El 13 4 11 ,07 /2024 05 37 ®❑pM in a Work Zone? NJ o1RP co
1 1T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
1 2 ❑ 2 99 r r ❑PM El Construction *
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM '
oNu 1 ® 13 4 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
r 2 0 ARREST NAME ❑AM
T ❑PM 0 Unknown work zone type U1
r r
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
298-Lopez, Mirko 601 275-Engelke r r ❑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••--, , I 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 truck trailer -<
—I
--'-----; I - } INDICATE ARROW
NORTH
combination):or p3
! a
2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
X
L L____A___.� Not To Scale I transporting emploned to yees inthe course 5 or fewer passengers
their emaployment nd operated
xample:employee
a contract ner
} } } po Y
® l transporter-usually a van type vehicle or passenger car):or 73
C
L L_____L____� / ~LuJ U 1. } 1. •4. Is used or designated to transport between 9 and 15 passengers,induding[hedrNer, y
is v �v,44 for direct compensation(example:large van used for specific purpose):or O
___� crywt7bt 11 i t i i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
_ D
CARRIER NAME —I
Z
ADDRESS 0
C
ICITY/STATE/ZIP g
_ MOTOR CARR.ID El Interstate El Intrastate
I r I ❑ Not in Comm./Govt. 0 Not in Comm./Other
, _Y_ __ I USDOT NO. ILCC NO. rn
m
XI
Source of above z
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No -Ti
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE