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HomeMy WebLinkAbout2024-00081252 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 010101 0 II 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a675962 u, 1 U21 3 4 1 U1 7 U2 1 u, 1 1_12 1 u1 1 U2 1 1 10 u, 1 U2 3 *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 ❑$501-$1.500 ®ON SCENE 16 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00081252 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mPAGE AVE El07:14 ® ❑ RELATED ®Y 0 N 12 30 2024 ®AM ❑YES El NO U1 —< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION MFT l MI N E S W DUNDEE DEE AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0 4 / yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1 M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 4 COM VEH 0 Ea 1 0 I= 60110 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1 ZEY83856 IL 2025 REAR TELEPHONE IL D 7 J F1 SF65592G733209 STATE FARM ❑Y ®N U2 1-- in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 1 99 9 Same 0147718-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 9 2 eu g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 NOV ❑Dv /1 9 7r 2 Lexus RX350 2022 00-NONE 11 12 i '-_, DUE TO CRASH ❑ 2 o ©-UNDER CARRIAGE 10 l 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 0 POINT OF s i 4 COM VEH 0 ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 5 I'"_ FIRST CONTACT 6 Y__{_O ._5 •(ryes,See SidebarC Z CH I CAG O I L 60626 0 1 0 DC72733 I L 2025aR 0 Z IL A 7 2T2HZMDA7NC317401 PROGRESSIVE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 1 99 9 Same 989099436 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused ID RESPONDER Y 9 u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 06 / F 2 4 0 1 0 m / / #OCCS D Xl / / U1 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 12,30 l2024 07 14 ®❑AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 28 99 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 —a, ARREST NAME / / El PM ' o u1 ® 11 `1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 30 T 2 ARREST NAME AM 7 / / ❑❑PM El Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 374-Rizzu-o. Michael 201 275-Engelke / / ❑❑pM Workers present? ®N U2 30 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 i- }__ _r_ --; f r 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer combination):or -< _ _ INDICATE NORTH 71 DI? BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C / 1 - (example:shuttle or charter bus):or C ® r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O }.--'A-'-'i J ' } } } transporting employees In the course ofo employment(example:employee 0 ! p,� � transporter-usually a van type vehicle or passenger car):or 03 ' . 4. Is used or designated to transport between 9 and 15 passengers,including rCjt }--- ----; I t - •} } } g PD passen rs,includi the driver, Not To Scale i for direct compensation(example:large van used for specific purpose):or L L-__..i.. . ' t i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •u placarding(example:placards will be displayed on the vehicle). XI __ —1 / yp,,e CARRIER NAME Z ADDRESS n1 T. / W ! n CITY/STATE/ZIP C) I MOTOR CARR.ID 0 Interstate 0 Intrastate 5 r 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 USDOT NO. ILCC NO. 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. 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 ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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 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. Z Red Bluew 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 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE