HomeMy WebLinkAbout2024-00075033 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 101101100
II M III II fll IOU 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036 53490'
u, 1 U21 13 4 1 U1 8 U2 1 U1 1 U2 1 U1 1 U2 1 5 12 U1 13 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00075033 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
S RANDALL RD El08:35
® ❑ RELATED ❑Y ®N 11 27 2024 ❑AM ❑YES M NO U1
_ g PRIVATE mo !day/yr ®PM FLOW CONDITION III
FT!MI N E S W SOUTH ST COUNTY PROPERTY ❑Y M N DOORING Ely #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 -I
M AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST M N M FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
f tf TOWED U1 Q
FOR DAMAGEDAREA(S) FROM
Adair.Ann.T. 1 1 /
yr 13-UNDER CARRIAGE ) ! FIRE 0 M
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED M 0 U2 2 f11
F 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN ENGAGE0 99-UUNKNOWN 9 16-TOP 3 ,Distraction Value 6 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_i L 6 ii,4 COM VEH 0 M 1
~ SCHAUMBURG IL 60173 0 1 FIRST CONTACT 1 7_; __5 *IIYes.SeeSidebar Ut 0
ZX386517 IL 2024 E
TELEPHONE
IL D 0 4A4AP3AU9FE017368 STATE FARM ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR • m
ADAIR.SARAH 2499353SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NCv ❑Dv
!2 0 0 2 Hyundai Elantra 2009 00-NONE Q l 12 . 2 FIRE TO CRASH D ® U2 2 C
Ti 13-UNDER CARRIAGE
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:, 4 COM VEH D ® U1 CO
FIRST CONTACT 11 7�_, _5 •(ryes.See Sidebar
H ELGIN Z IL 60123 0 1 0 BL85573 IL 2025REAR
M
IL D KMHDU46DX9U812317 ALLSTATE ❑Y M N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 RICH.SCOTT.A. 912174446 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 / F 2 4 0 1 U2 996 m
/ / #occs >
/ / UI 2 D
/ / 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 11 ,27 l2024 08 35 ®pm in a Work Zone? M 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 �
o"
2 ❑ 26 18 1 1 ❑PM ❑Construction *
1
Z3 ❑ M CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
o ® 11 1 ARREST NAME Adair.Ann.T. 11-708 W441-800 ! ! El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
45
t 2 ❑ ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
441-Alva. Edwin sot , ! 0 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
1 1 ADDITIONAL UNITS FORMS.
r ----r•---, , I I 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 I I. INDICATE NORTH combination):or A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L i I I - } (example:shuttle or charter bus):or
® I I 3. Is designed tocarry 15 or fewer passengers and operated a contract career 0
}---------•i esg pa g pe by
Not To Scats 1, I I ` } } } transporting employees In the course of their employment(example:employee w
r transporter-usually a van type vehicle or passenger car):or CO
L L.__-a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y— — — — - } } • •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L i L i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
CARRIER NAME Z
iiii— O
I I ~ I ADDRESS T.
I CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I3 ❑ Not in Comm./Govt. 0 Not in Comm./Other 0
------- --4. - : : : <
I I USDOT NO. ILCC NO. m
PCI
Source of above Z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
71
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations MCS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
LOCAL USE ONLY TRAILER VIN 2 m
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Blue.Dark
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE