3126400*Fpo *If Yes to Hazmat Spill Or Com Veh, Complete Commercial Motor Vehicle Area on Back
ILLINOIS TRAFFIC CRASH REPORT Sheet of Sheets DRAC PEDV TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV PPA PPL *3126400*FPO *IF YES TO HAZMAT SPILL OR COM VEH, COMPLETE COMMERCIAL MOTOR VEHICLE AREA ON BACK. *3126400* U1 U2 U1 U2 U1 U2 U1 U2 U1 U2
1A 1A TYPE OF REPORT TRFW INVESTIGATING AGENCY DAMAGE TO ANY $500 OR LESS A No Injury / Drive Away AGENCY CRASH REPORT NO. ON SCENE ONE PERSON’S $501 - $1,500 NOT ON SCENE (DESK REPORT) VEHICLE / PROPERTY B Injury and / or Tow Due To Crash OVER $1,500 AMENDED YR VEHT ADDRESS NO. HIGHWAY or STREET NAME City Township INTERSECTION DATE OF CRASH TIME LARS CODE 1B 1B RELATED Yes No AM U1 mo/ day / yr PM PRIVATE : (CIRCLE) (CIRCLE) COUNTY PROPERTY Yes No CIRCLE DAY OF WEEK NUMBER MOTOR LARS CODE FT / MI N E S W SU MO TU WE VEHICLES INVLD HIT & RUN Yes No TH FR SA U2 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) NO. LANES NAME DRIVER PARKED - NO DRIVER PED PEDAL EQUES NMV NCV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) YN FOR DAMAGED AREA(S) TOWED / / 00 - NONE DUE TO CRASH (LAST, FIRST, MI) mo day yr 10 - UNDER CARRIAGE FIRE ALGN STREET ADDRESS SEX SAFT AIR PLATE NO. STATE YEAR 11 - TOTAL (ALL AREAS) 12 - OTHER HAZMAT * 99 - UNKNOWN SPILL CITY STATE ZIP INJURY EJECT VIN POINT OF COM VEH * RSUR FIRST CONTACT *IF YES SEE SIDEBAR TELEPHONE DRIVER LICENSE NO. STATE CLASS VEHICLE OWNER (LAST, FIRST M.I.) INSURANCE CO. VEHU UNIT 1 TAKEN TO EMS AGENCY OWNER ADDRESS (STREET, CITY, STATE, ZIP) TELEPHONE POLICY NO. U1
NAME DRIVER PARKED - NO DRIVER PED PEDAL EQUES NMV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) YN FOR DAMAGED AREA(S) TOWED U2 00 - NONE DUE TO CRASH (LAST, FIRST, MI) mo/ day / yr RDEF 10 - UNDER CARRIAGE FIRE STREET ADDRESS SEX SAFT AIR PLATE NO. STATE YEAR 11 - TOTAL (ALL AREAS) 12 - OTHER HAZMAT SPILL *
Printed by authority of the State Illinois 99 - UNKNOWN CITY STATE ZIP INJURY EJECT VIN BAC POINT OF COM VEH * FIRST CONTACT *IF YES SEE SIDEBAR U1 TELEPHONE DRIVER LICENSE NO. STATE CLASS VEHICLE OWNER (LAST, FIRST M.I.) INSURANCE CO. UNIT 2
TAKEN TO EMS AGENCY OWNER ADDRESS (STREET, CITY, STATE, ZIP) TELEPHONE POLICY NO. U2 # OCCS (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) PASSENGERS & WITNESSES ONLY (NAME) / (ADDR) / (TEL) (HOSP) (EMS) U1 / / / / U2 DIRP / / U1 / / / / U2 U (EVNO) (MOST) (EVNT) (LOC) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY CONTRIBUTORY POSTED N 1 CAUSE(S) SPEED LIMIT I PROPERTY OWNER ADDRESS CITY STATE ZIP PRIMARY T 2 *P0109* 1 3 ARREST NAME SECTION CITATION NO. SECONDARY *P0109* U ARREST NAME SECTION CITATION NO. DATE POLICE NOTIFIED TIME NOTIFIED N 1 AM I mo /day /yr : PM T 2 OFFICER ID. SIGNATURE BEAT / DIST. SUPERVISOR ID. COURT DATE COURT TIME AM SR 1050 JANUARY 2009 SR 1050 JANUARY 2 3 mo /day /yr : PM REMEMBER TO USE BLACK INK, PRESS HARD, PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! Proof #2 10-03-2008 8510043949
FACE PART 1 OF 3. SCREENS 10% 8510043949 LOCAL USEONLY 1ClrU2Color U1 Towed by /to U1 Color NARRATIVE (Refer tovehicle by UnitNo.) XXXXXXX REGULAR BACKER PART 1 OF 3. even if A Diagram units have beenmoved prior to theofficer’s arrival. and Narrative are required onall U2 Towed by /to Type B crashes, INDICATE NORTH BY ARROW Was aDriver/Vehicle ExaminationReportformcompleted? OA EIL EGH____f NO. OFAXLES______MILESNESWOR ______TRAILER2 ______ft CRASH LOCATION: TOTAL VEHICLELENGTH ______ft >102” TRAILER LENGTH(S): 1______ft 97-102” 0-96” TRAILER WIDTH(S): IDOT PERMITNO. ______WIDELOAD? the crash? violationcontributeto Did MotorCarrierSafetyRegulations(MCS) Did HAZMAT Regulationsviolationcontributetothecrash? vehicle’s owntank)? Did HAZMAT spillfromthevehicle(donotconsiderfuel No LogBook Yes Driver Were HAZMAT placardsdisplayedonthevehicle? Papers Gross Vehicle Weight Rating(GVWR)______SideofTruck Source ofaboveinfo. USDOT NO. CITY/STATE/ZIP ______ADDRESS CARRIER NAME______displayed onthevehicle). (HAZMAT) thatrequiresplacarding(example:placardswillbe 5. Isanyvehicleusedtotransporthazardousmaterial for specificpurpose);or from thedriver’sworkreportinglocation(example:largevanused including thedriver, fordirectcompensationbeyond75airmiles 4. Isusedordesignedtotransportbetween9and15passengers, vehicle orpassengercar); employment (example:employeetransporter-usuallyavan-type contract carriertransportingemployeesinthecourseoftheir 3. Isdesignedtocarry15orfewerpassengersandoperatedbya including thedriver(example:shuttleorcharterbus); 2. Isusedordesignedtotransportmorethan15passengers, or truck/trailercombination); 1. Hasaweightratingofmorethan10,000pounds(example:truck passengers orpropertyand: A CMVisdefinedasanymotorvehicleusedtotransport SELECT CODESFROMBACKCOVER OFCRASHBOOKLET: COMMERCIAL MOTORVEHICLE(CMV) Form No.______MCS HAZMAT 4-digit UNno.______1-digitHazardClass______If yes,nameonplacard______IF MORETHANONECMVISINVOLVED, USESR1050A CARGO BODY TYPE______LOAD TYPE______e o Unknown No Yes TRAILER 2 TRAILER 1 ______ILCCNO. ______e o Unknown No Yes VEHICLE CONFIGURATION ______e o Uk Oto evc? e No Yes UnkOutofService? No Yes e o Uk Oto evc? e No Yes UnkOutofService? No Yes ADDITIONAL UNITSFORMS. ICEOECITYNAME CIRCLE ONE e o Unknown No Yes IYO O NEARESTCITY CITY OFOR
e No Yes
B1A B1A COMPLETE BOTH SIDES OF THIS FORM Mail This Report to Use black ink Illinois Department of Transportation Crash Records Section For a copy of the Police *3126400*FPO ILLINOIS MOTORIST REPORT 3215 Executive Park Drive Report contact the Springfield, Illinois 62766-0001 investigating agency. *3126400*
2A 2A TYPE OF REPORT INVESTIGATING AGENCY DAMAGE TO ANY $500 OR LESS A No Injury / Drive Away AGENCY CRASH REPORT NO. ON SCENE ONE PERSON’S $501 - $1,500 NOT ON SCENE (DESK REPORT) VEHICLE / PROPERTY B Injury and / or Tow Due To Crash OVER $1,500 AMENDED YR ADDRESS NO. (OPTIONAL) HIGHWAY or STREET NAME City Township INTERSECTION DATE OF CRASH TIME LARS CODE 2B 2B RELATED Yes No AM mo/ day / yr : PM PRIVATE (CIRCLE) (CIRCLE) COUNTY PROPERTY Yes No CIRCLE DAY OF WEEK NUMBER MOTOR LARS CODE FT / MI N E S W SU MO TU WE VEHICLES INVLD HIT & RUN Yes No TH FR SA AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) NAME DRIVER PARKED - NO DRIVER PED PEDAL EQUES NMV NCV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) YN FOR DAMAGED AREA(S) TOWED / / 00 - NONE DUE TO CRASH (LAST, FIRST, MI) mo day yr 10 - UNDER CARRIAGE FIRE STREET ADDRESS SEX SAFT AIR PLATE NO. STATE YEAR 11 - TOTAL (ALL AREAS) 12 - OTHER HAZMAT * 99 - UNKNOWN SPILL CITY STATE ZIP INJURY EJECT VIN POINT OF COM VEH * FIRST CONTACT TELEPHONE DRIVER LICENSE NO. STATE CLASS VEHICLE OWNER (LAST, FIRST M.I.) INSURANCE CO. UNIT 1 TAKEN TO EMS AGENCY OWNER ADDRESS (STREET, CITY, STATE, ZIP) TELEPHONE POLICY NO.
NAME DRIVER PARKED - NO DRIVER PED PEDAL EQUES NMV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) YN FOR DAMAGED AREA(S) TOWED 00 - NONE DUE TO CRASH (LAST, FIRST, MI) mo/ day / yr 10 - UNDER CARRIAGE FIRE SEX SAFT AIR PLATE NO. STATE YEAR STREET ADDRESS 11 - TOTAL (ALL AREAS) 12 - OTHER HAZMAT SPILL *
Printed by authority of the State Illinois 99 - UNKNOWN CITY STATE ZIP INJURY EJECT VIN POINT OF COM VEH * FIRST CONTACT TELEPHONE DRIVER LICENSE NO. STATE CLASS VEHICLE OWNER (LAST, FIRST M.I.) INSURANCE CO. UNIT 2
TAKEN TO EMS AGENCY OWNER ADDRESS (STREET, CITY, STATE, ZIP) TELEPHONE POLICY NO.
Was driver (owner) of other vehicle insured? YES NO NOT KNOWN YOUR INSURANCE Were you driving a vehicle owned by your employer, in the course of your employment? If yes, check square. If you fail to give full information below it will be assumed that you did not have automobile liability insurance, and DID POLICE OFFICER INVESTIGATE ACCIDENT?YESNO APPROXIMATE COST TO REPAIR YOUR VEHICLE $ you may be subject to further application of the Safety LIST PERSONS KILLED OR INJURED UNIT AGE SEX Responsibility Law. *M0109* NAME ADDRESS Were you covered by a liability insurance policy at the time of the crash? YES NO DESCRIBE INJURIES Full name of your insurance company (not agency) which *M0109* issued policy to cover liability for damages or injury to others. NAME ADDRESS
DESCRIBE INJURIES
NAME ADDRESS Name and address of representatives who sold policy. DESCRIBE INJURIES
DESCRIBE DAMAGE TO PROPERTY OTHER THAN MOTOR VEHICLESAPPROXIMATE COST PROPERTY OWNER'S NAME TO REPAIR Policy Number
PROPERTY OWNER'S ADDRESS Policy Period $ From: To: ADDRESS DATE Name of Policy Holder SR 1 JANUARY 2009 SR 1 JANUARY SIGN HERE Mail This Report to Illinois Department of Transportation Crash Records Section Drive 3215 Executive Park Springfield, Illinois 62766-0001 Signature of person making report COMPLETE BOTH SIDES OF THIS FORM 8510043949
FACE PARTS 2 & 3 OF 3. SCREENS 10%, GREEN DENOTES SPOT CARBON TISSUES PARTS 2 AND 3 DIAGRAM WHAT HAPPENED 3. Use solid line to show path THE PROVIDING OF FALSE before crash: INSTRUCTIONS PRINT OR TYPE ALL INFORMATION IS A CLASS C 1. Follow dotted lines to draw INFORMATION MISDEMEANOR AND CAN RESULT IN A outline of roadway at place ON THIS FORM. $500 FINE AND A 30-DAY SENTENCE. of crash. dotted line after crash: INDICATE NORTH 2. Number each vehicle and The Safety Responsibility Law BY ARROW show direction of travel by THIS REPORT IS For general information only arrow. 4. Show pedestrian by: CONFIDENTIAL AND (See Sections 625 ILCS 5/7-100 through 5/7-216 of the 5. Show railroad by: CANNOT BE USED AS Illinois Vehicle Code for complete statute.) 6. Show utility poles by: EVIDENCE IN ANY In certain cases drivers and owners may be required to 7. Show motorcycle by: prove financial responsibility. usually by presenting TRIAL. evidence of automobile liability insurance. DIAGRAM LEGAL REQUIREMENTS When any person sustains property damage in excess As the driver of a motor vehicle involved of $1,500 (or, $500 if any driver is not insured) or personal in a traffic crash causing death, injury, injuries, the names of uninsured motorists are sent to the or damage to any one person’s vehicle Secretary of State with a legal notice of possible security or property exceeding $1,500, you deposit. The notice names all potential property damage must complete and submit this report. and bodily injury claimants, and lists the evaluated amounts
of the potential claims. The evaluations are based on B2A B2A However, if you or any other driver in information shown in the reports filed by drivers or owners. the same crash does not have It is important that reports be filed promptly and that insurance, you must complete and complete and accurate descriptions of property damage submit this report if damage to any one and bodily injuries be shown in the spaces provided on the person’s vehicle or property is over report form. $500. The accident file, which usually contains a police report In either case, your report must be and a report from each driver, will be sent to the Secretary completed and submitted within 10 of State. That office will review the reports to ascertain days after the crash. if the uninsured driver was legally at fault. If the driver was clearly not at fault, the file will be closed; otherwise a If a driver is physically incapable of Notice of Suspension will be mailed. The notice of completing this report, the owner or Suspension outlines the Methods of Compliance with the another occupant of the vehicle should Illinois Safety Responsibility Law; it also advises the do so. uninsured motorist of the right within 15 days of the Notice INSTRUCTIONS of Suspension to request a hearing. If a request for hearing is not received, the suspension becomes effective OBSERVE THE FOLLOWING RULES: 45 days from the date of the Notice of Suspension. If a 1. PRINT ALL NAMES AND ADDRESSES. hearing is held and the Hearing Officer concludes, after 2. Answer all questions to the best of considering all written and oral evidence, that there is a your knowledge. If unable to reasonable possibility of legal fault, the uninsured motorist answer any questions, mark "NK" has the following options: 1. Deposit security; for "not known." 2. Present evidence of releases from liability (or signed NARRATIVE (Refer to vehicle by Unit No.) 3. The nature and extent of all agreements to pay for damages in installments) from all damages and injuries must be potential claimants named on the security deposit notice; clearly and completely stated. 3. Show evidence of a final adjudication of nonliability. If Whenever a doctor's statement of the uninsured motorist fails to comply with any of the injuries or a garage estimate of the above options, his/her drivers license (if driver) and cost of repairs is immediately vehicle registration privileges (if owner) would be available, give this information; otherwise, give your own careful suspended. estimate. (None of the above affects any person's right to sue to 4. Use a second report form or a recover damages.) sheet of paper the same size to report additional vehicles, injured (Security deposits, releases, or installment agreements persons, witnesses, or any other are to be submitted to the Secretary of State.) information for which there is not sufficient space. THIS SPACE FOR FLEET OPERATORS ONLY 5. SIGN THE REPORT in the space at the bottom of the front side of this If your vehicle is subject to the Federal Motor Carrier Safety report form. Regulations, provide your USDOT number below: Important - This crash should also be reported to your insurance representative. Failure to report may jeopardize your automobile liability insurance. ______USDOT number
Has the Department of Insurance issued a certificate of self-insurance covering your vehicle?
YES NO 8510043549
REGULAR BACKER PARTS 2 & 3 OF 3.