HomeMy WebLinkAbout2024-00073935 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100
I 111111 0111 01100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo0363.183
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INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash
El AMENDED
YR 202412024-00073935 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
137 S STATE ST Elgin
® ❑ RELATED ❑Y ®N 11 22 2024DAM ❑YES ®NO U1
03:23
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
ID AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) ROM TOWED U1 0
Unknown.0. Unknown Unknown 00-NONE ,, • 12 OUETOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,Il a li._ 1 0
I— 0 9 FIRST CONTACT 1 7_; _5 *ir Yes.See Sidebar Ut
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
NONE ❑Y ❑N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NONE 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N❑l N 0
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N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCV 0 Dv
!1 9 8 2 Volkswagen GTI 2016 00-NONE O,' t2 "_, DUE TO CRASH ❑ 2
0 y 13-UNDER CARRIAGE 10 I 2 FIRE ID El U2 C
c
M 2 8SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 9
POINT OF s i1 �i COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5
FIRST CONTACT 11 7 , 5 •If Yes.See Sidebar
Z WEST DUNDEE IL 60118 0 1 0 EQ46823 IL I 0
IL 0 3VW4T7AU2GM070445 STATE FARM ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 1855706SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 co 11 9 11 (22 l2024 03 20 ®PM AM in a Work Zone? NJ DIRP D
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 8 0
v 1 T 2 0 2 06 1 ( _ 0 PM El Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME ( ! ID PM '
oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
t 2 ❑ ARREST NAMEAM
T ( / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 50
1519-Bae2 a.Guadalupe 701 ( / ❑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••--, , ; 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 -' J I r INDICATE NORTH combination):or -I
Leeusnst BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L 1 I 8 ?81 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
-- - } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
I. L.___a__._.l IC
4. Is used ordesi natedtotrans rtbetween9and15passengers,indudingthedrrver,
0 I. } } • •
for direct compensation(examp large van used for speific purose):or
L L `
___� '�orataavtst I i. i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Not To Scefe I placarding(example:placards will be displayed on the vehicle).
unit CARRIER NAME Z
_, I ADDRESS 0
I l
CITY/STATE/ZIP C)
- i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
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
Blue.Dark
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 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE