HomeMy WebLinkAbout2024-00070753 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 a2 Sheets 01111101111
I01101100 IIIIII VOIDIIIIDII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003637769
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202412024-00070753 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mHIGGINS RD Elgin
® ❑ RELATED ❑Y ®N 11 06 2024 ❑AM ❑YES ®NO U1 —<
PRIVATE mo /day/yr 05:14 ®PM FLOW CONDITION m
_
10(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 U.)® C.7!MI NOS Vtr Galvin Dr WITH VEHICLES INVLD IN STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FRONT TOWED TOWED U1 Q
Lackin er. David. F. Ford Escape 2016 00-NONE „ , DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) g mo yr 13-UNDER CARRIAGE 1a.I 2 : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 15-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
F• FIRST CONTACT 12 7_II• a 4_5 *If Yes.See Sidebar U1 COM VEH ❑ j$J 1 0
Z Chicago I L 60646 0 1 S699542 I L r' _,
TELEPHONE
IL D 0 1 FMCU9J96GUA50225 Travelers ❑Y ign4 U2 ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6133243142031 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NCv 0 DV CIRCLE NUMBER(S) U1
$ 1 9 9 6 Kia Motors Coilptima 2017 00-NONE 1.11 t2--_, DUETO CRASH ❑ 2 x
o Yr 13-UNDERCARRIAGE ta;l 2 FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
I 4 COM VEH ❑ ® U1 COS
FIRST CONTACT 6 7A- I'_5 •If Yes.See Sidebar C
— Algonquin IL 60102 B 1 DZ81113 IL PEAR 9
IL D 5XXGV4L25HG160454 Progressive ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 976603943 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (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 ❑Y U2 Z
N 1 ® 11 1 11 ,61 )024 05 14 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 28 18
N 3 ❑ CITATIONS ISSUED 0 PENDING + ) - ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
—a ARREST NAME / / ❑PM '
o, N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
t 2 ❑ ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 5U
547 Homeier.William 272-Bajak , i ❑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-- --' I - r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I Hlgglna7(Rl?72) _ } (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} -A-.--i
} } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
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L L.___a__._.lft 4. Is used ordesi natedtotrans rt between 9 and 15passengers,includingthedrrver,
I. } } for direct compensation(examp large van used for speific purose):or 0
L L--_-a-.... 4 - t i. i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ,Zmt
Approx.71007feeti I - -- —I
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GeINn7Dr CARRIER NAMEZO
\. - ADDRESS D
CITY/STATE/ZIP 0
0
- MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I I 0 Not in Comm./Govt. Not in Comm./Other
0 0
� --- --4, I USDOT NO. ILCC NO. m
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE