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HomeMy WebLinkAbout2024-00078659 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV u, 1 U2 1 1 2 U1 1 U2 U, 1 1_12 U, 1 U2 5 14 U1 3 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00078659 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N MCLEAN BLVD Elgin 08:02 ® ❑ RELATED ®Y 0 N 12 15 2024 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W W HIGHLAND G H LAN D AVECOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW fA ❑ 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 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 7 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 SY15-OTHER 4 ❑Y ❑SNE®UNK VEH. 9 ATCRASD M IN ENGAGE9 99-UNKNOWN 9 t6•TOP 3 ,Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a 4 COM VEH 0 Ea 1 0 ~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1 Z WAXED-B IL 2025 REAR TELEPHONE IL D 0 1 FTYR1ZM8GKA65147 State Farm ®Y 0 N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Nightingale. Michael. D. 0758475-SFP-13 2 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' 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 row yr 12 _ C1 o 13-UNDER CARRIAGE t�.i :., FIRE 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 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-6 COM•I sVEH See •Sidebar❑ 0 C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YDNDER❑N U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 El 11 1 12!15 ,2024 08 02 ®AM in a Work Zone? NJN DIRP co PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 0 T 2 0 v t12!15 /2024 08 02 mi PM 0 Construction * Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 ARREST NAME 12/15/2024 08 02 ®PM o U 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 t 2 0 ARREST NAME 12!15 /2024 08 27 ®PM 0 Unknown work zone type 0 AM U1 30 n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 494-Kirsh. Katherine 701 01 , 14,2024 09 00 ❑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 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or x 3. Is L 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____.I L L L ...._-..i._ 1 t 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 i. ADDRESS 0 fh CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m 73 Source of above z ) ❑ Side of Truck [0 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 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. P3 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 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 0 No 2 TRAILER VIN 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 White U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO. Artier/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE