HomeMy WebLinkAbout2024-00076508 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100
'MINN
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a653249
u, 1 u21 2 4 1 u, 2 U299 u, 1 U2 1 u,99 U2 99 1 12 u, 1 u2 1 *P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00076508 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
1425 N RANDALL RD Elgin11:27
® ❑ RELATED 0 Y ®N 12 05 2024 ®AM ElYES El NO U1 -<
_ _ PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 5 Cl)
❑ FT/MI N E S W Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
ID AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
F9ctir TOWED U1 0
Willard. Dou las. F. Chevrolet Astro Van 2005 00-NONE it_ t2 , DUE TO CRASH 0
NAME(LAST,FIRST,M) g mo yr 13-UNDER CARRIAGE i1
FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
O 2 0 DISTRACTED 0 U2 0 171
M 2 4 ❑Y ❑SNE❑ is-OTHER
UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;i�6 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 10 7 ; _5 *II Yes.See Sidebar U1
ZS668140 IL 2025 REAR
M TELEPHONE
IL D 0 1 G N DM 19X25B103970 Country Financial ®y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same P12A8644596 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 0
m g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 NPAy 0 NOV 0 Dv CIRCLE NUMBER(S) U1
/1 9 5 9 Other Other 2022 00-NONE 11__' t2"0 DUE TO CRASH 0 ! l 29 x
0Yr 13-UNDER CARRIAGE 10 2 FIRE 0 El U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 7� _, _5 •If Yes,See Sidebar
~ ELGIN IL 60123 0 1 M234389 IL 2025 RE 4 ((I)
M
IL A 7 1 N9ALALM5NC084161 Pace Bus ❑Y ❑N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Pace Suburban Bus Di N/A BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) OHJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 7 01 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
N 1 El 11 1 12/05 /2024 11 28 Z
®❑PM in a Work Zone? NJ N DIRP D
co
T
1 r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
v 2 ❑ 2 28 1 / _ 0 PM El Construction *
Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a N ® ARREST NAME / / ID '
1 11 1 0 CITATIONS ISSUED ❑PENDING
SECTION CITATION NO. ROAD CLEARANCE TIME El
UtilitySLMT
o
,
0 AM
r 2 0 ARREST NAME 12/05 /2024 12 15 0 PM El Unknown work zone type U1 10
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
0 Y 10
1525-NavE.Oscar 502 275-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. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' r-' INDICATE NORTH combination):or .Z�1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Lit,t
(example:shuttle or charter bus):or X
1 1 1 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
< :- -A--- 1 } } } transporting employees In the course of their empbyment(example:employee
L -----}----; 1� �-- - I. } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and r 15rpassen passengers,including the dryer,
� 11 I?RondaU for direct compensation(example:large van used for specific purpose):or to
L L____a.....: RdffraWinL i. i. t 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Oti placarding(example:placards will be displayed on the vehicle). ;p
C--- L .. .. ..... .....
CARRIER NAME Z
ADDRESS 0
r >
�~ O
T CITY/STATE/ZIP g
MOTOR CARR.ID ❑ ta ❑
1 I r ❑ NotInters in Cotemm./Gout. Not inIntrastate Comm./Other
; _Y_ __, USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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-; 0 Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE