HomeMy WebLinkAbout2024-00075615 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111
I01101100
III I Ol IV 10100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003643775
u, 9 U21 1 1 1 U,99 U2 1 u,99 u2 1 U1 99 U2 1 5 10 U1 99 U2 -3-1 *P 0119�K
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 0 ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00075615 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
DUNDEE AVE Elgin09:50
® ❑ RELATED ®Y 0 N 11 30 2024 ❑AM YES ®NO U1 -<
_ g PRIVATE mo /day!yr ®PM FLOW CONDITION m
FT!MI N E S W STEWART AVE COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 4 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 is-Top 3 0 0 _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN 6 l 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 1I C.OM VEH 0 E! 1 0
I• FIRST CONTACT 99 7_:I_ *IIYes.See Sidebar U1
0 9 9 UNKNOWN RE
2 Z
_ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I—
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 9 0
m
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 r uv 0 NCv 0 DV
yr
�1 9 6 6 Honda HR-V 2025 00-NONE ,�_.i 12'-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 1 E FIRE ❑ ® U2 C
c
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracnon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 I 6 .!.,_4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 6 7 -�-_5 •(ryes,See Sidebar C
ELGIN IL 60120 0 1 0 EY82817 IL FIRST
0 fp
M
IL 3CZRZ2H50SM700782 Encompass Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2025276565 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 12,01 (2024 08 27 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 18
N 3 0 0 CITATIONS ISSUED 0 PENDING ( 1 0 PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
-a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
SLMT
35
t 2 0 ARREST NAME AM
7 ( r ❑❑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 35
558-Lara. -izette 201 404-Duffy 1 ( ❑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
A. 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` -'- -' d - 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
I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} -A----1
r } } } transportingemployees In the course of their employment(example:employee
Qj!L transportr-usually a van type vehicle or passenger car): r w
Lr. m""'"" 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
L L t 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle).
1.9
, CARRIER NAME Z
ADDRESS 'n
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
MX lif Stele ' 0I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS c
❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No z
Form Number 0
m
71
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
Silver White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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