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HomeMy WebLinkAbout2024-00078057 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II MDVI 1011100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a657422 u1 1 U2 1 1 1 U1 1 U2 U1 1 U2 U1 1 U2 4 4 U1 1 U2 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00078057 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n CORRON RD El In06:21 ® ❑ RELATED ❑Y ®N 12 12 2024 ❑AM ❑YES ®NO U1 -< g PRIVATE mo /day!yr ®PM FLOW CONDITION m FTlMI N E S W CONGRESSIONAL PKWY COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EDUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 4 / yr 13-UNDER CARRIAGE ©,I '._2 FIRE 0 NIC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m F 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it �i 4 COM VEH El j$J 1 0 1— _FIRST CONTACT 11 7_ ,__-a_;__5 *IIYes.See Sidebar U, 0 Z ELGIN IL 60124 0 1 0 DN18997 IL 2025 RER TELEPHONE IL D 0 3VWG57BUXKM081191 Cincinnati Casualty Compa ❑v ®N U2 ni 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same A011170526 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEOAI 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr 12 _ 71 o 13-UNDER CARRIAGE I 2 FIRE 0 0 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 *Oistraellon Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 8 . :-6 C•IO e1sVEH See •Sidebar❑ 0 C CO F` ----- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑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 < RESP❑YDNDER❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / / UI 1 D 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 16 1 Arroyave. Maria. L. Black dog 12,12 ,2024 06 21 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 .. v t 2 0 3689 OPEN PKWY ELGIN IL 60124 21 99 ! ! ❑PM ❑Construction * Z3 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ❑PM o N 1 • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 45 SLMT F 2 ARREST NAME AM 7 ! r ❑❑PM 0 Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ - IDAM Workers present? ❑y 1515 BellEck.Stacy 801 ! , ❑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 -< c ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w 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 II < <--_-a _�-__ ,1,-� I t } } } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m �' : placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z ADDRESS 0 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn 73 Source of above Z . GVWR/GCWR m 0 <10,0oo 0 10,000-26,000 0 >26,000 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 co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White u 1 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