HomeMy WebLinkAbout2024-00073676 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets HUI III 11 111111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV
u, 1 U2 1 1 3 U1 4 U2 U, 1 1_12 U, 1 U2 1 5 U1 1 U2 *P 0119*
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 El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00073676 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r7
RUSSELL RD/WINDING HILL DR Elgin 12:39
® ❑ RELATED ❑Y ®N 11 21 2024 DAM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 ()
0 6 /
yr p( 2021 Jeep FOR
19680nd Cherokee 00-NONE 0• Oj 0 DUE TOCRASH ® 0
13-UNDER CARRIAGE D) 2 FIRE 0 NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 M
F 2 SYTM 8 ❑Y ❑SNE®UNK VEH. 9 AT CRASH 9 99-U 15-UNKNOWN THER O9 t6-TOP 3 ,Distraction Value 9 ALGN -
F0
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST NTOONTACT 12 O7 _'4i-0 CIfDYes.See Sidebar VEH ❑ U1 El 1 0
... Loves Park IL 61111 B 1 0 Z811461 IL 2025 REAR
TELEPHONE
IL D 0 1 C4RJKBG3M8114379 First Chicago ❑Y ign4 U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 926457 FC 423 3 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value U1 9 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT YA=1-.:=5 C•IO e1sVEH See •Sidebar❑ 0
C
CO
F` pEAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 Q
❑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 <
RESPNDER❑YO❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL) n
1 3 06 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 2 3 City of Elgin Fiberglass Marker Stake 11 ,21 /2024 12 39 ®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 t 2 0 150 DEXTER CT ELGIN IL 60120 11 18 , r 0 PM ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME / / ❑PM
o N 0 •
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
45
t 2 ARREST NAME AM
r / ❑❑PM ❑Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME CIY
326-Hornsby. Marc 800 272-Bajak 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
A ADDITIONAL UNITS FORMS.
r ----r••--, , N 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 -<
c ` -'- -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - i. (example:shuttle or charter bus):or 0
- ------;-•--; - transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employeener X
y a van type
< <.___a____J Ono, . } 1 transporter sedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,includingthedrrver,
r
c
,.._�— wlndag7Hm?or. t } }
•
for direct compensation(example:large van used for specific purpose):or N
L L____a____� _ l. i I 5. Is any vehicle used to transport any hazardous material(HAZMAT) m
— placarding(example:placards will be displayed on the vehicle). ;p
—I
CARRIER NAME Z
,.,:. ADDRESS 0
T.
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
5
❑ Not in Comm./Govt. 0 Not in Comm./Other 0
a , <
------- --1 ~' - 't USDOT NO. ILCC NO.
m
I — Not To Scale f 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 ❑ No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
El Yes Yes II No 0 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 ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
XI
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
11
TRAILER 1 ❑ ❑ 0 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 ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE