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HomeMy WebLinkAbout2024-00078213 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11I1 mil U Ill1 HO 11 HIll 11 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03661498 u, 9 u21 3 4 1 u, 5 U2 1 U,99 U2 1 U,99 U2 1 1 10 u, 4 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00078213 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1 N 190 El ❑ RELATED ®Y 0 N 12 13 2024 02:15 ❑AM ❑YES ®NO U1 —< Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m ®15 ®!MI N E s © West Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl) Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD DO U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 8 , FOR DAMAGEDAREA(S) FR0f4r TOWED U1 Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 161 !�. 2 FIRE 0 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 04 M SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 9 9 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 iL 6 i.r.4 COM VEH 0 0 1 C) I— 0 9 0 FIRST CONTACT 5 7_: _O •II Yes.See&debar U1 0 Z 697330ST IL ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 NIA ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 RT GROUP LOGISTICS I NIA 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER '5RESPONDER Y°®N ( C)) m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NuV 0 Ncv 0 Dv 1 9 8 5 Volvo VN L 2025 00-NONE 012.._, DUE TO CRASH ❑ ® 20 0 13-UNDER CARRIAGE 10 I 2 FIRE ❑ El U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `OiSIractJDn Value 9 0 POINT OF 8 i1 1I 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 11 7 , _6 •(ryes,See Sidebar = FORT PIERCE FL 34950 0 1 0 3682237 IN 2025 REAR 0 FL A 7 4V4NC9EH5SN669018 Acord ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 B Express Logistics RPQN02082024 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 m #occs y 71 / U1 1 m 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,13 /2024 02 15 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 97 2 0 20 18 N 3 0 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a, ARREST NAME / / ID PM ' o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 40 r 2 ARREST NAME AM 1 r ❑❑PM 0 Unknown work zone type U1 El Cf 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 40 1537-Mapp.Teddron 502 334-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. 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 -< ` ` --I -' I. INDICATE NORTH combination):or .Z-1 ' I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I I - } (example:shuttle or charter bus):or L }----A---•i Ir" 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I } transporting employees In the course of their employment(example:employee Nor �.,,s1 transporter-usually a van type vehicle or passenger car):or CO -- -- I ,I - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or 0 L L____a____. IJ !''? i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ty y _ _ _ placarding(example:placards will be displayed on the vehicle). XI rr' 3 {CARRIER NAME Z I ADDRESS I 0 T. w n CITY/STATE/ZIP g - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other I. -- : - USDOT NO. ILCC NO. rn 73 Source of above 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. XI XI 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 No 0 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 VIM 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE