HomeMy WebLinkAbout2024-00079490 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111 I0110110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003671903
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00079490 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
BIG TIMBER RD El07:07
® ❑ RELATED ' V 0 N 12 20 2024 ®AM ❑YES El NO U1
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N STATE ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FPO Ni TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ t2 , DUE TOCRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE i FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OD. 2
SYSTEM IN ENGAGED 15-OTHER 09 16.70P 3 DISTRACTED 0 ]$I U2 0
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
$ 4 COM VEH 0 ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _i _,Il_6 lit_ 1
I— 0 9 FIRST CONTACT 10 75 *Ir Yes.See Sidebar U1 0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same Unknown 3 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
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N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ ivy 0 CIRCLE NUMBER(S) U1
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/ Yr 1 9 9 2 Subaru Forrester 2018 Do-NONE 13-UNDER CARRIAGE ,�_` t2 "_, DUE TO CRASH ❑ 2
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 0916•TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN ''II *Distraction Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 1 O 07._H�I�S C•IO e1s.VEH
See Sidebar❑ ® U1 CO
Z Algonquin IL 60102 0 1 CW31514 IL 2025 REAR
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IL D JF2SJAGC4JH543030 American Family Ins ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
Same 41 068-321 1 9-75 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N 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 ® 11 9 12(20 l2024 07 07 ®❑PM AM in a Work Zone? ®N DIRP D
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1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n
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v 2 0 28 2 ( ( 0 PM 0 Construction *
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Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
-a, ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
t 2 0 ARREST NAME AM
T ( 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? ❑Y 30
430-Nemtev.Sergey 501 275-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
r r ADDITIONAL UNITS FORMS.
r r---- ----1 , / ; 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 -<
N combination):or -C
r }----i-----i r / INDICATE NORTH rZ1
Not To Scale I / / BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
/ / } (example:shuttle or charter bus):or
X
/ f 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
- } } } transporting employee In the course of their employment� (example:employee � X
/ / transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including w
-- -- } } } g po passen rs,includi the driver,
Rif / for direct compensation(example:large van used for specific purpose):or O
i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
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/ /�/ CARRIER NAME Z
/ ^/�/ _ __ ADDRESS D
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CITY/STATERR.I- MOTOR CARR.ID ❑ Interstate ❑ Intrastate O❑ Not in Comm./Govt.N❑ Not inComm./Other O
; _Y_ _-1 I USDOT NO. ILCC O. m
XI
Source of above z
. -I
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
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE