HomeMy WebLinkAbout2024-00073314 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0O3645591
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00073314 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 mN RANDALL RD El In 04:24
® ❑ RELATED ❑Y ®N 11 19 2024 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT
FT!MI N E S W ROYAL BLVD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 10 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
2023
1 1 /
yr 13-UNDER CARRIAGE ) FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
O O DISTRACTED 0 ]$I U2 6 171
F 18 4 SYTM❑Y ®NNE❑UNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP® •Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_i[6 i� 4 COM VEH 0 El 1 0
H 1- LAKE I N THE HILLS I L 60156 0 1 0 FIRST CONTACT 12 r: _-s *II ves.See Sidebar U1
Z 85AV59 IL 2023 REAR
TELEPHONE
IL M 0 J KBZXVM 11 PA004314 NONE ❑Y 0 N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NONE 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 c
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMv 0 NOV ❑DV
yr 10 j 12 (, 2 FIRE ❑ ® U2 C
0 13-UNDER CARRIAGE
c
M 18 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9116•TtOP3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN • •Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 00 7�'8- I�1:,=5 4 COM•IfYes V.
EH See Sidebar❑ ® U1 CC
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= ELGIN IL 60123 0 1 0 12A000 IL 2024 REAR—
M
IL M 0 JS1GW71A672104420 NONE ❑Y ❑N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same NONE BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 1 04 / F 18 3 0 1 0
m
/ / #OCCS D
/ / u1 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,19 /2024 04 24 ®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 C)
0 2 03 15 / / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a RAY.CONNOR.J. 3-707 S1519000224 / / PM
-, ARREST NAME El
o U 1 ® 1 1 1 CITATIONS ISSUED 0PENDING TIME • 0 Utility SLMT
o NSECTION CITATION NO. ROAD CLEARANCE 0 AM 55
r 2 El ARREST NAME Hambrick. Hakeem. L. 3-707 S1519000224 r / pM Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 55
1519-Bae2 a.Guadalupe 602 334-Fries 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
ADDITIONAL UNITS FORMS.
r ----r•---, , - ; 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- combination):or —I
} r , / r INDICATE NORTH C
/ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C)
/ _ } (example:shuttle or charter bus):or
/ / N7MNDALL7R0 , , , , T,
/ / 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} -A- -•i `
` } } } transportingemployees In the course of their employment(example:employee
p
/ ti // transporter-usually a van type vehicle or passenger car):or
L L.__-a-_ 4. Is used ordesi natedtotrans rtbetween 9 and 15 passengers,includingC} } } peg ( p transport g p orthe dryer,
7://
t ROYQ4aLw for direct com nsation exam le:lar a van used fors cific ur O
sr L -a-...j 4. 4 4 L 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requiresm1 / placarding(example:placards will be displayed on the vehicle).
/�"' Z/ � CARRIER NAME Z_NO SW J ADDRESS 'n/ U)C)
/ CITY/STATE/ZIP g
/ - MOTOR CARR.ID 0 Interstate 0 Intrastate 5
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
r ;____Y___ 1 USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 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 0 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? A
❑ Yes II El 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 0 Unknown Out of Service ❑Yes ❑No C
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
Green Black
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: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE