HomeMy WebLinkAbout2024-00073194 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El 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 202412024-00073194 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 9 -n
PLANK RD Elgin
® ❑ RELATED ❑Y ®N 11 19 2024 ®AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 02:49 ❑PM FLOW CONDITION m
rj COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW fA
® FT/® NOS W Murfield Rd WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
IYg3 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 2 0
FOR DAMAGEDAREA(S) FRO TOWED U1 Q
Sbone.Anthony, 0 4 /
yr
13-UNDER CARRIAGE
1 I: 2O FIRE ❑ ®
10 C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 ❑Y ®SYis-OTHER
SE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 16-TOP() `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 it COM VEH r ❑ 1 0
F. FIRST CONTACT 1 7__,--_;_OS •IIYes.See Sidebar Ut 0
Z Hoffman Estates IL 60192 0 1 0 76083TVZ IL 2024 REAR
TELEPHONE
IL A 7 1XPFDT9XXXN478728 Country Financial ❑Y ®N U2 ni
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Pingree Grove Fire Metz,Timothy, M. P010174270 2 m
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
yr 12 _ 71
o 13-UNDER CARRIAGE 10.i :., FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value U1 3 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I,_
CIO es See SidebarEH
0 C
CO
F` REAR` 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
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 2 3 Shipler.Stephanie. M. mailbox destroyed 11 ,19 /2024 03 00 ®❑PM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 ,,
v t 2 ❑ 40W905 PLANK RD Hampshld� 60140 11 15 11,19 ,2024 03 00 ❑PM ❑Construction
Z3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ®AM ❑Maintenance U2
-a, ARREST NAME 1 1/19/2024 03 15 ❑pM
u 1 ❑ ❑CITATIONS ISSUED ❑PENDING Utilit SLMT
o
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ y
AM u,_ 55
t 2 ElARREST NAME 1 1/1 9 /2024 04 00 M PM ElUnknown work zone type
cf T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ - ❑AM Workers present? ❑Y
469 Taylor,Jonathan 807 / 0 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•---, , Not To Scale I I % A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I - 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- % combination):or —I
INDICATE NORTH
4 N- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or
oa 3. Is designed to carry15 or fewer °` A ig passengers and operated by a contract carrier i O
- } } } transporting employees in the course of their employment(example:employee X
'Prtvra0e7�dve transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
•
Pe ( P 9 Pe or•
L L i. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
- i
• , placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Tim Metz Farming Z
ADDRESS 41W586 RUSSELL RD
T.
CITY/STATE/ZIP PLATO CENTER 1 IL 160170 M
- i. 4. MOTOR CARR.ID 0 Interstate El Intrastate
I I . ; MWMbId?dtve ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
-- --1 — — — — — % % % uSDOT NO. None ILCC NO. None C
x
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes ® No =
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 ® 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?
❑ Yes II No ElUnknown A
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. None WIDELOAD' 0 Yes ®No =
TRAILER VIN 1 1TDH400221 B099578 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ M Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver
u 1 TOWED TOTAL VEHICLE LENGTH 60 f ft. NO.OF AXLES 8
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. 6 CARGO BODY TYPE 9 LOAD TYPE 1