HomeMy WebLinkAbout2024-00079642 (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 3 4 1 U1 1 U2 u, 1 U2 U, 1 U2 5 10 U1 1 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00079642 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED PRIVATE ®Y ❑N 12 20 2024 DAM ❑YES ®NO U1 -<
S RANDALL RD Elgin mo /day/yr 07:00 ®PM FLOW CONDITION M
E02O qC7!MI N E O W Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
(g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FRONT TOWED EN
U1 0
(LAST,FIRST,M) lovino. Brandon. P. 0 mo 4 /
13-UNDER CARRIAGE 10 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 99-UNK 15- NOWN THER9 t6•TOP 3 *Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a iI all,. COM VEH 0 jK 1 C)
~ ELGIN IL 60124 0 1 0 FIRST CONTACT 7 O7 ::L _-5 *II Yes.see Sidebar U1 0
Z CG79318 IL 2024 REAR
TELEPHONE
IL D 0 1 C4RJ FBG6JC356518 Farmers ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 193416783 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 rg-
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 KDV 0 DV
yr 12 _ 71
o 13-UNDER CARRIAGE 1U I c. 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 0 SPDR O
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:=5 C•IO e1sVEH See •Sidebar❑ 0
C
CO
F` pEAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) iSEATI (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
3 4 06 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 12/20 /2024 07 01 ®AM in a Work Zone? ®N DIRP co
T 2 0
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 0
o t L 12 12,20 /2024 07 01 ®PM El Construction
>F
R 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
ARREST NAME 12,20/2024 07 10 ®PM
o U 1 0 CITATIONS ISSUED PENDING UtilitySLMT
o N 0 AM SECTION CITATION NO. ROAD CLEARANCE TIME • El
t 2 El ARREST NAME 12/20 /2024 08 15 ®PM El Unknown work zone type U1 50
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
1541-Wilkerson.Tondeo 801 246-Kite 11 , 31 /025 01 30 ❑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 -, , ; ; , 1, ( combination):or —I
INDICATE NORTH X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' , } (example:shuttle or charter bus):or
x
3. Is
. 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____.l L L L L.__-..i._ 1 L 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
th
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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
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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIM 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: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE