HomeMy WebLinkAbout2024-00074374 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 01000II IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00364.15f
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INVESTIGATING AGENCY DAMAGE TO ANY El g500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑g501-S1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00074374 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH -n
® ❑ RELATED ❑Y ®N 11 24 2024 DAM ❑YES ®NO U1
SUMMIT ST Elgin10:23
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W DUNDEEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl)
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGED AREA(S) FRONT TOWED U1 0
Durkee. David.S. 1 1 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 R<1
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�6 4 COM VEH 0 0 1 0
ELGIN1 . IL 60120 A 1 0 FIRST CONTACT 15 7 ; _5 *lIYes.See&debar U1
REAR
c Z E
TELEPHONE
IL D 0 NIA ❑Y 0 N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 48 1 Same NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 row 0 NCV ❑DV
yr 1
0 j 12 c, 2 FIRE ❑ ® U2 C
o 13-UNDER CARRIAGE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 9 ENGAGED 9 15-OTHER 9:1,6•TtDP 3 0 ® SPDR 0
9 4 ❑Y ❑N ®UNK VEH. AT CRASH ® UNKNOWN *0istracton Value U1 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- L 6 j1:-4 COM VEH ❑ ® CO
FIRST CONTACT 99 7�� _,_.5 •If Yes.See Sidebar
~ 0 9 0 3394707B IL 2023 REAR 9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 GCRYDEDXKZ232073 Unknown 0 Y 0 N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 48 1 Perez.Jesus Unknown BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
RESPONDER
Y°®N U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
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71
/ UI ' D
/ 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
co
N 1 ® 12 1 11 ,24 /2024 10 24 ®PM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 0
2 24 99 11,24 ,2024 11 24 ❑PM ❑Construction
F
1
Z 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
ARREST NAME 11,24/2024 10 46 ®PM
1 ® 12 1 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o u2. El
®AM U1
r 2 0 ARREST NAME 11 r 24 /2024 11 00 PM ElUnknown work zone type
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 99
1512-Juarez-Huichapan.Juan too 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.
t.r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i<„ I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }____r__--; I I } combination):or
Not TO Scale I ; INDICATE NORTH p0
C
n � �I I - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
- } (example:shuttle or charter bus):or
L A t I y I Summer 3. Is designed to carry 15 or fewer passengers and operated a contract carrier I O
} } } transporting employees In the course of their employment(example:employee
^�"� transporter-usually a van type vehicle or passenger car):orco
L }-----}----; - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example:large van used for specific purpose):or
— 1 1 0
a < i. } _} 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
I I ADDRESS 0
IC)
CITY/STATE/ZIP g
-I i. i. i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
Y
USDOT NO. ILCC NO. m
Source of above z
. 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'; 0 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
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE