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HomeMy WebLinkAbout2024-00073740 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 0 lfl 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a6385O9- u, 1 U2 1 1 1 U1 4 U2 U, 1 U2 U, 1 U2 5 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 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 3 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00073740 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 21 2024 ❑AM ❑YES ®NO U1 -< LONGCOMMON PKWY Elgin mo /day/yr 05:14 ®PM FLOW CONDITION m ®50 ® © COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW CO !MI N E S South St WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 1 0 / yr . Q 13-UNDER CARRIAGE �0 i , 2 FIRE 0 IE C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m F 2 4 ❑Y ®SNEM❑ is-OTHER UNK VEH. O AT CRASH IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 i'.4 COM VEH 0 LK 1 0 ~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 1 Y ; _O •Ir Yes.See Sidebar U1 0 Z EF55535 IL 2024 REAR TELEPHONE IL D 0 3VWRM71K58M126400 GEICO ❑Y ®N U2 ni 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 6183997771 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 N4y 0 Kcv 0 DV yr 12 _ 71 o 13-UNDER CARRIAGE 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 0 0 SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 3 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-5 COM•I sVEH See •Sidebar❑ 0 C CO F` ---,- 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❑YDNDER❑N U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 0 1 3 City of Elgin black light pole damaged 11 ,21 /2024 05 14 ®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 ,, ;, 2 ID 34 3 150 DEXTER CT ELGIN IL 60120 28 99 ! ! ❑PM• ❑Construction * t Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME Logan. Precious. D. 11-601-Ax 1530000148 / / El PM SLMT o u 1 ❑ 0 CITATIONS ISSUED ❑PENDING Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ t 2 0 ARREST NAME 1 1 1 21 12024 06 02 ®PM 0 Unknown work zone type U1 30 0 AM n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 1530-Soto.Oscar 801 11 r 12 ,25 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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z �____r____, 0 I } combination): r more than pound (example:truck ortruckrtrarler 1. Has a weight rating10 000 5i -< INDICATE NORTH o p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C Not lb Scale I I _ (example:shuttle or charter bus):or 0 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 ..7 transporter-usually a van type vehicle or passenger car):or w L I 4. Is used or designated to transport between 9 and 15 passengers,including N }--- Sauth9st } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O __ _a_ 1 _ _ _0#/11_ _ _ _ — _ � t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires u placarding(example:placards will be displayed on the vehicle). XI /— L i. i. ..... ..... —1 CARRIER NAME Z ADDRESSn CITY/STATE/ZIP n I MOTOR CARR.ID ❑ Interstate ❑ Intrastate Longcommon?Pkwy O I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 0 Yes II No ❑ Unknown 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. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m to 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black 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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE