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HomeMy WebLinkAbout2024-00060205 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 0111 III I IIIIIII II 111111111111111111101111111111111 IIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035 974 u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 4 11 Ut 1 u211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE • 3 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00060205 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 S RANDALL RD El ❑ Elgin RELATED ❑Y coN 09 19 2024 07:32 ❑AM ❑YES ®NO U1 ,< PRIVATE mo l day I yr ®PM FLOW CONDITION m 1:02°(]0 O 'COUNTY PROPERTY El ®N DOORING ❑'' #OF MOTOR ❑SLOW 1 N I MI N E S W BOWes Rd 'WITH VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRNER 0 PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑SIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 FOR DAMAGED AREA(S) FRONT DUE TO CRASH TOWED U1 NAME(LAST,FIRST,M) ,V. Toyota00-NONE Highlander 2017 mo 1 1 / day J yr t1_ QI -1 CI13-UNDERCARRIAGE 19 (21 1• I 2 FIRE ❑ Ll 3 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ISI 0 U2 m 1221 NAVY CT F ❑Y IN NSYSTEM❑LINK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 1 ALGN I CITY PLATE NO. STATE YEAR POINT OF 6 I� e l 4 COM VEH ❑ ® 1 O STDJZRFHOHS379151 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 1551520-SFP-13 1 r Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G0 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) fr20 IT TOWED NAME(LAST,FIRST,M) Adrovic. Mirza 11m day 1 9 8 2 Honda Civic 2023 00-NONE i1 12 s REoCRASH 0 ® U2 2 C I', 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 IN SPUR 0 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X E. 2274 DORCHESTER CT M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value tV CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j i 4 COM VEH ❑ ® U1 to F, FIRST CONTACT 6 7_-_on-5 •If Yes,See Sidebar ELGIN IL 60123 0 DV86577 IL 2025 I 0 C. M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)616-6027 A361-5408-2314 IL D 0 2HGFE2F58PH510050 State Farm ®Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same K256059-A13-13A BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER® Same U1 = (UNIT) ;SEAT) (DOBi (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAMEI/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) - 2 3 09 /1 8/1960 M 2 4 0 1 0 Ajro Adrovic/2274 DORCHESTER CT,ELGIN.IL.60123 Refused 996 m (514)699-4063 , U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 11 1 91 ,91 /024 07 33 ®pm in a Work Zone? El DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 1 C) T 2 0 03 41 1 I 0 PM El Construction * c' 3 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q ARREST NAME Solis,Anastasia,V. 11-710-A W499000706 / / ❑PM SLMT 21 11 1 ❑Utility p U ❑CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 'd N 8 AM 45 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut r,f Co T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 499-Dirck Cameron 801 334-Fries / / ❑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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' r } A CMV is defined as any motor vehicle used to transport passengers or property and. Z r- -r- --, , r r"- - 1 r r r , , , , . 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r •• ; i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L I ', ! (- L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------t-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' t ADDRESS 0 N • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r•---, i '- DO ILCC NO. m U N XI , Source of above Z _ m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 rn 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Black Silver - 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/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE