HomeMy WebLinkAbout2024-00076545 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 6 Sheets HUI III 11 111111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV
u, 1 U2 1 1 1 U, 1 U2 U, 1 u2 U, 1 U2 1 9 U121 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ElS501-51,500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ® 6 Injury and for Tow Due To Crash YR 202412024-00076545 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 -n
1524 DAVIS RD Elgin 02:38
® ❑ RELATED ❑Y ®N 12 05 2024 ❑AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER N PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EouES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
NT TOWED U1 0
FOR DAMAGEDAREA(S) .FROM
WILLIAMS. BRENDA. K. 0 1 /
yr 13-UNDER CARRIAGE I 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 rr1
F 2 SY4 ❑Y ®SNEM IN❑UNK VEH. 0 ATCRASHD 0 99-UUNKNOWN O9 t6.7pP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail �'.4 COM VEH ® 0 1 00
H 1- POPLAR GROVE IL 61065 B 1 0 FIRST CONTACT 11 T_: __S *If Yes.See Sidebar U1
Z104459SB IL 2025 REAR
TELEPHONE
IL B 7 4UZABRFC7MCMH5340 OLD REPUBLIC INSURANCE CO ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 FIRST STUDENT. LSE MWTB-316836-24 1 rn
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
28 X
rg-
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 DV
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracI n Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 [j_6 CIO es See SidebarEH 0 C
CO
F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0
3 7 06 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 5 12,05 /2024 02 38 ®pm in a Work Zone? ®N DIRP co
T 2 ❑
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 0
a 1 12,05 /2024 02 45 ®PM ❑Construction *
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ELMS ARRIVED TIME
❑AM ❑Maintenance U2
ARREST NAME 12/05/2024 02 49 ®PM
o u 1 ❑ CITATIONS ISSUED PENDING UtilitySLMT
o N 0 AM SECTION CITATION NO. ROAD CLEARANCE TIME • ❑
t 2 El ARREST NAME 12/05 /2024 04 53 0 PM ❑Unknown work zone type U1 1 O
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? ❑
1 542 Chafe. Ethan 501 334-Fries / ❑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.
0 A CMV is defined as for vehxae used to tra and:
r :----,5-•---, ; any mo nsport passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} }-- -;-- --; } } } r -, , ; ; , ; ( combination):or —I
INDICATE NORTH X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' , } (example:shuttle or charter bus):or
x
3. Is
. L.___A_. 1 i. ... . J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 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 L___-a____.l L L L ...._-..i._ 1 L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
th
CITY/STATE/ZIP In
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
: -Y- --; : : l- Y- ; ; : 0651 USDOT NO. 35 ILCC NO. m
73
Source of above z
) ❑ Side of Truck Li Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes ® No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. P3
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® 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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes ®No 2
TRAILER VIM 1 m
to
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 3 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Yellow
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE