HomeMy WebLinkAbout2024-00076007 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 11
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00076007 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® ❑ RELATED ' V 0 N 12 03 2024 ❑AM ❑YES ®NO U1 -<
RT20 WB Elgin09:40
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
®!MI N E S W S State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 Co
Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
gi 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 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Unknown,O. mo / / yr Unknown Unknown 00-NONE „ O i-, DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 : 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 4i,4 COM VEH 0 Ea 0
I 0 9 FIRST CONTACT 12 7 : ( _5 *IrYes.See Sidebar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
unknown ❑Y ❑N U2 I-
5 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 IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.5D Y°N0 N D Ai
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g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0!My 0 i v 0 Dv
!1 9 yf 4 Toyota Highlander 2022 00-NONE 'o,� t2 (,-2 FIRE DUE o CRASH ® U2 2 cXj
o 13-UNDER CARRIAGE El
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F 2 4SYSTEM IN ENGAGED 15-OTHER 9.1,6•TOP 3 9 X
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1I,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 5 7 —_,SOS •(ryes,See Sidebar
ELGIN I L 60120 0 1 BQ43350 I L REAR 9 Sn
M
IL D STDFZRBH4NS184435 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Hoffman,Steven, R. 937230279 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 9 12,03 /2024 08 29 ®❑PM AM in a Work Zone? ❑N DIRP D
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1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
Eri 2 03 18
N 3 0 0 CITATIONS ISSUED 0 PENDING / ! - ❑PM, ®Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 6
-a, ARREST NAME ! / 0 PM '
o N El 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
AM25
7T 2 ❑ 1 1 ❑❑PM 0 Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 20
556-Reuter,Craig 701 275-Engelke , / ❑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 I 1 I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
I- i-- -'-- --' I 61$1610st 1 - r INDICATE NORTH combination):or -1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
II } (example:shuttle or charter bus):or
l® r 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
---A-----I I I ,
, - } } } transportingemployees In the course of their employment(example:employee � X
I Not To Soots J transporte -usll a van type vehicle or passenger car): r CO
L L.___a____� VYB?RPl1tYlEnfraftoeP - I. } } } C
•4. Is used or designated to transport between 9 and 15passengers,including the driver, N
1 �"P� for direct compensation(example:large van used for specific purpose):or O
.p t i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
•{ placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
I ADDRESS 0
I to
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0 Not in Comm./Govt. ❑ Not in Comm./Other 00
1- --- --1 - USDOT NO. ILCC NO. C
m
73
Source of above z
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
Xl
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
Blue
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE