HomeMy WebLinkAbout2024-00075875 ILLINOIS TRAFFIC CRASH REPORT sheet 1 or 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00364.1,5
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
El AMENDED
YR 202412024-00075875 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
® ❑ RELATED ❑Y ®N 12 02 2024 ❑AM ❑YES ®NO U1
N STATE ST Elgin04:53
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
5 !MI N E S W WingSt COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
g32 Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 1 /
yr 13-UNDER CARRIAGE 10 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n
F 2 SY 15-OTHER
8 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value 7 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�s 4 COM VEH 0 1� 1 0
~ ELGIN I L 60123 B 1 0 FIRST CONTACT 12 7_: __5 *IIYes.See Sidebar U1
Z D244158 IL 2025 REAR
TELEPHONE
IL D 0 2C4RDGCG2KR679422 Teacher's Insurance ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 2C4RDGCG2KR679422 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Sherman ❑Y El 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑row 0 NCV 0 DV CIRCLE NUMBER(S) U1
yr Q. 12 ,Q C
0 13-UNDER CARRIAGE 10 I E FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S r. COM VEH ❑ ® Ut W
FIRST CONTACT 6 O7 :-=Q)OS C.
If Yes.See Sidebar C
ELGIN I L 60124 0 1 0 SOX104 I L 2025aRSi)0
IL D 0 1 FMCU9DG6BKB23401 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 949613907 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
3 6 07 / M 2 3 0 1
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/ / #OCCS D
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/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,21 l024 04 53 ®pm 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
Er 2 0 28 03 ) ) 0 PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Graff. Pamela.S. 11-601 492000471 / ! El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
30
t 2 0 11 1 ARREST NAME AM
7 1 ! ❑❑PM 0 Unknown work zone type U1
%
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
492-Gardrer. Mikaela 601 334-Fries 11 , 11 ,025 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N.?State?91. 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
;•--
i- . _.r --__ ; INDICATE NORTH combination):or
P3
a°' "I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i 1 } (example:shuttle or charter bus):or 0
IS3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- . . . transporting employees In the course of their employment(example:employee X
1,$ transporter-usually a van type vehicle or passenger car):or w
C
r"_i; P0.1. I. } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, ((I)
!R! for direct compensation(example:large van used for specific purpose):or O
L t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
r placarding(example:placards will be displayed on the vehicle). ,Zt
CARRIER NAME Z
VNnp?St. 1 I ADDRESS
U)
acre Not To Scale I 0
_ CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------ ----4. - USDOT NO. ILCC NO. m
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 0 No 0 Unknown M
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
Xl
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE