HomeMy WebLinkAbout2024-00076863 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00076863 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
427 MCCLURE AVE EIIn00:12
® ❑ RELATED ❑Y ®N 12 07 2024 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW 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 O PARKED l]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
1 2 FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
NAME(LAST,FIRST,M) French. Pierre.J. mo / /1 9 8 7 General MotorA, Tip 2008 00-NONE 11 O i_, DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE ❑ IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 9 9 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHD15-OTHER
0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRISTOONTACT 12 Y il:rA1i,•5 CuOM VEH Ye SeeSidaDar❑ El U1 1 0
0
Z ELGIN IL 60123 0 9 0 EJ89358 IL 2008 ri
TELEPHONE
IL D 1GKEV13728J225407 Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 0
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0 i v 0 DV
yr Hyundai Sonata 2012 00-NONE 11 t2 "_, DUE TO CRASH ❑ ® 1 ,'a
o 13-UNDER CARRIAGE FIRE 0 ® U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC
a SYSTEM IN 0 ENGAGED 0 15-OTHER ()IS-TOP 3 0 ® SPDR 0
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Distrac on Value 9 U1 0 -
POINT OF s I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ij 6 i'_ COM VEH ❑ ® CO
F,,, FIRST CONTACT 2 7�._� _s •If Yes,See Sidebar
DN89268 IL 2025 RE 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5NPEC4AB4CH459673 National General ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Lynch.Sharron 2024338891 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEATI (DOBI (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTHI PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 co
12(07 /2024 00 12 ®❑PM AM in a Work Zone? ®N DIRP D
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 30 50
N 1 3 ❑ CITATIONS ISSUED 0 PENDING ( 1 ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a ARREST NAME / / ❑PM
o U 1 ® • ❑Utility
1 1 1 0 CITATIONS ISSUED PENDING SLMT
o N 35
SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 ❑ 1 1 1 ARREST NAME 12/07 /2024 00 1 2 MPM ❑Unknown work zone type U1cf
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1513-Mann. Nathaniel 601 391-Jacobucci / / ❑❑PM Workers present? ®N U2 35
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
451 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 truck trailer -
` ` '' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
- } (example:shuttle or charter bus):or
alarm. T,
L 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 X
transporter-usually a van type vehicle or passenger car):or w
L I.___a__._J 4. Is used ordesi natedtotrans transport passengers,including (I)
} } } g po passen rs,includi the driver,
McCNme}Ave. for direct compensation(example:large van used for specific purpose):or O
L i...__a____. I - l. i i. ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
placarding(example:placards will be displayed on the vehicle). m,Zt
CARRIER NAME —I
rit ADDRESS D
IN t ` V)
1
Unit 2 0
CITY/STATE/ZIP g
_ I I _ r t MOTOR CARR.ID 0 Interstate El Intrastate
I I . I mp. i I ❑ Not in Comm./Govt. Not in Comm./Other 00
I ____ ____ I Untt i _ ,
Y Not To Scale USDOT NO. ILCC NO. m
m
XI
Source of above z
. 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue,Dark Black
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE