HomeMy WebLinkAbout2024-00080036 ILLINOIS TRAFFIC CRASH REPORT sheet 1 or 4 Sheets 01111101111 I01101100
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2024I 2024-00080036 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
W HIGHLAND AVE El In 06:50
® ❑ RELATED ®Y ❑N 12 22 2024 ❑AM ❑YES ®NO U1
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FTlMI N E S W WING PARK BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Butler.Cole. N. 0 1 /
yr 13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED ® 0 U2 O m
M 2 6 El ®$NE❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UUNKNOWN 016 3 `Distraction Value 9 ALGN =
1• CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF 6 . 00--;__
TELEPHONE
IL D 1 N4AA6AP8JC398404 USAA ❑Y ®N U2 r'I R
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire GRETCHEN. BUTLER 03352-12-82F-7103 4 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 XI
�{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑row 0 Ncv ❑Dv
!1 9 yf 3 Chevrolet Traverse 2022 00-NONE 0. Ql'-O DUE TO CRASH 0 D 2 x
o 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ ® U2 C
M 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI�1:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
Z ELGIN IL 60123-5421 B 1 0 EL91830 IL 2025 I> 0 C
IL D 1 G N EVG KWOMJ 137495 STATEFARM ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire TMC DECONSTRUCTION L 3488508-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 City of Elgin.City of Elgin Fire Hydrant tipped over 12,22 l2024 06 50 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 150 DEXTER CT ELGIN IL 60120 23 99 , , _ 0 PM ❑Construction >E
4
Z 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, U 1 ARREST NAME Butler.Cole. N. 11-1204-B s1533-000191 / ! El PM SLMT
o ER 1 0 Utility
0 CITATIONS ISSUED PENDING
o0 AM
N SECTION CITATION NO. ROAD CLEARANCE TIME
t 2 0 1 2 ARREST NAME 12 r 22 l2024 07 30 0 PM 0 Unknown work zone type U1 30
2 2 3 ❑ 34 2 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1533-Ruiz.Jose 601 334-Fries 11 , 41 ,025 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.
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----; I } combination)or
INDICATE NORTH -1
W Is used or designed to transport more than 15 passengers including the driver —I
} } i.i. e. r RR (example:shuttle or charter bus):or
YA
Not To Sce/e 3. Is designed tocarry5 fewerpassengers andoperated contractcarrier esg 1 or ated by a 0
< }.___A.._.J ,M,rq, I - y } } } transport) em to ees In thecoursee of thir em ng p y pbyment(example:employee X
�y ,� transporter-usually a van Type vehicle or passes r car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including C
}--- ----; - } } } g po passes rs,indudi the driver,
4c9ii ir for direct compensation(example:large van used for specific purpose):or
L L _a unnz - i. < i. L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
stu�endzAra CARRIER NAME Z
ADDRESS 'n
V)
CITY/STATE/ZIP XI
Edkon9Avw C
--irl
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 USDOT NO. ILCC NO. 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
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
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE