HomeMy WebLinkAbout2024-00078583 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil III 0 IftIl
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV
u, 9 U2 1 1 2 u, 2 U2 1 U1 99 1_12 U,99 U2 1 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00078583 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 '1
1940 MARK AVE Elgin10:02
® ❑ RELATED ❑Y ®N 12 15 2024 ®AM ❑YES El NO U1
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
COUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FPO Ni TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE EN
<
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y El N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH ❑ ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[S !i,_ 1 00
I- 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unI—
known ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Same unknown 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99 0
m
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 i v 0 DV
yr 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C
Ti
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ® SPDR 0
❑Y ❑N D UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 -
POINT OF 8' 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -d�',_ COM VEH D ® CO
FIRST CONTACT 1 Y -5 • •It Yes.See Sidebar
H AC68181 I L 2025 I:EaR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5XYPG4A38HG207252 Allstate ®Y ❑N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Daniel. Patricia 962325162 BAc $
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)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 12!15 l2024 10 02 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 99
N 3 0 0 CITATIONS ISSUED 0 PENDING / 1 ❑PM, ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
z
—a, ARREST NAME / / ❑PM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
10
t 2 0 ARREST NAME AM
7 ! r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? D Y 10
337-Thompson.Charles 502 404-Duffy / / ❑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.
.- .. , A CMV is defined as any nator vehicle used to transport passengers or property and: Z
r r 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ' • INDICATE NORTH combination):or p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
Not To Scale _ (example:shuttle or charter bus):or
X
. 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 73
transporter-usually a van type vehicle or passenger car):or w
L L.___a__._. 4. Is used ordesi natedtotrans transport passengers,including N
} } } g po passen rs,includi the driver,
um� . • •
for direct compensation(example:large van used for specific purpose):or O
' L.___a____. (---. 4949..Mw* - l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
aitail Ave,... placarding(example:placards will be isplayed on the vehicle). XI
w.. —1
CARRIER NAME Z
ADDRESS 0
ta
0
CITY/STATE/ZIP g
_ - MOTOR CARR.ID 0 Interstate ElIntrastate 5
i.
0I I T I ❑ Not in Comm./Govt. 0Not in Comm./Other
I I I I
r USDOT NO. ILCC NO. m
73
Source of above Z
. If Yes,Name on placard 0
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?
❑ Yes II No El Unknown A
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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE