HomeMy WebLinkAbout2024-00070978 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
01101100 0110000100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003622115
u1 1 U21 1 1 1 U1 U2 1 U1 1 U2 1 U1 1 U2 1 4 11 U, 1 U2 1 *P 0 1 1 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 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00070978 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mRANDALL RD El ❑In RELATED ❑Y ®N 11 07 2024 06:16 ❑AM ®YES ❑NO U1 —<
g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
•1 FT/vt N E S W South Hopps Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 rA
® ® O pp Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROM TOWED U1 0Rivera.Judith 0 1 /
yr 13-UNDER CARRIAGE 10 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 99-UNK 15- NOWN THER9 16•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�S 4 COM VEH 0 Ea 1 0
ELGIN N I L 60123 C 1 0 FIRST CONTACT 99 7 ; _5 *Ilyes.See Sidebar U1
ZEY63872 IL 2025 REAR
TELEPHONE
IL D 0 1 GNALDEKODZ128096 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
South Elgin Fire Same 2618976sfp13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 My 0 KCV 0 Dv
/1 9 9 7 Dodge Ram 1500(pickup) 2024 00-NONE ,�_"j Q1:-_, DUETO CRASH ❑ cg 2 x
0 13-UNDER CARRIAGE 1a/ I. E FIRE ❑ ® U2 C
c
M 2 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
POINT OF s iI 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - MI'._
FIRST CONTACT 6 Y__{_ ._5 •If Yes,See Sidebar
= Algonquin IL 60102 0 1 0 3833252B IL 2025 REAR
0 C
IL D 0 1 C6SRFFT4RN160909 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 1701455sfp13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 06 / M 2 4 0 1 0
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,07 /2024 06 16 ®AM 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
v 2 0 03 18 11(07 /2024 06 17 ®PM ❑Construction >E
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Rivera.Judith 11-710-A 1545000037 11/07/2024 06 23 Igi pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
El AM
t 2 0 11 1 ARREST NAME 1 1(07 /2024 07 07 ®PM ❑Unknown work zone type U1 50
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
1545-VanEycke. Brier 702 11 (26/2024 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.
r ----r••--, , II I I 1 A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` ' ' I I I I - r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
— — — — ® - (example:shuttle or charter bus):or
HOPPS?ROAD X
— —L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
_ _ _ transporter-usually a van type vehicle or passenger car):or w
L L.___a._._.i 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
, t } } } • •
for direct compensation(example:large van used for speific purose):or 0
Ii i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
1 I . placarding(example:placards will be displayed on the vehicle). m
D
Not To Scale J 1 D
CARRIER NAME
4 ji , ' ADDRESS 0
w
'r l CITY/STATE/ZIP g
I _ MOTOR CARR.ID 0 Interstate 0 Intrastate
I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
` `----„----' S?RANDALLTROAD - USDOT NO. ILCC NO. C
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
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?El❑ Yes II 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-; ❑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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE