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HomeMy WebLinkAbout2024-00076603 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 0 M 011000 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00a651200* u, 1 U21 1 1 1 u, 1 U2 1 u, 1 1_12 1 u, 12 u2 1 5 7 u, 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (8:1B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00076603 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 71 ® ❑ RELATED PRIVATE ❑Y ®N 12 05 2024 DAM YES ®NO U1 -< WING ST Elgin mo /day/yr 05:50 ®PM FLOW CONDITION Ill 010 Or MI N E s © Garden Crescent St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Chaples. Brandon. L. 1 0 / yr 13-UNDER CARRIAGE ©.I FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 m M 2 4 n 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 .b... CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 *Yves.See Sidebar IA VEH 0 �! 1 O F. FIRST CONTACT 00 Y _,__5 Z McHenry IL 0 1 0 DT65900 IL 2025 TELEPHONE IL D 0 JTHBA30G045041336 None ❑Y ❑N U2 13 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1 Same None 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu p; DRIVER 0 PARKED 0 DRIVERLESS 0 KO 0 PEDAL 0 EWES 0 NMv 0 Nay 0 DV '1 9 yr 0 Toyota Highlander 2008 00-NONE 0" 12 "_, DUE TO CRASH ❑ (� 2XI 0 13-UNDER CARRIAGE 10 2 FIRE El ® U2 C c ii F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN ''DistractIon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .id.._ 4 C.OM VEH D ® U1 CO FIRST CONTACT 11 7 _, _5 •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 CQ49391 IL 2025 I 0 N IL D 0 JTEDS41A582032156 Safeway Insurance ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 406403-I L-PP-002 BAc $ 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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 19 1 12,05 ,2024 05 50 ®AM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 10 99 1 1 ❑PM ❑Construction * Z 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a1 ® 11 1 ARREST NAME Chaples. Brandon. L. 3-707 492000473 t r El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility ❑ 30 t 2 El ARREST NAME AM 7 1 ❑PM El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 492-Gardrer. Mikaela 501 01 ,21 ,2025 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 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< ` ` -'- ' r INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or Gerdee4Creecent4Dr. , , , , T, L A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I. } } transporting employees v in the course of their ant(example:employee w transporter-usually a van type vehicle or passenger car):or � \ I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C kviogyft �zn�r for direct compensation(example:large van used for specific purpose):or O L L____a____� e _ t l. I. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m placarding(example:placards will be displayed on the vehicle). ;p IND __ D P.O.r. -I CARRIER NAME ADDRESS 'Z Not To Scale I D CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate El Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _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 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 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE