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HomeMy WebLinkAbout2024-00061028 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 M U I 0 0 100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003562Pr57 u, 1 U21 1 1 1 U1 8 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 6 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202412024-00061028 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m739 N STATE ST El In 01:43 ® ❑ RELATED ❑Y ®N 09 23 2024 DAM ❑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 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FROM TOWED U1 O NAME(LAST,FIRST,M) y mo /1 9 5 4 T Mercedes-Ber�320 1998 00-NONE ,, • 12 , DUE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0U2 4 II n F 2 SYTM IN ENGAGETHER 4 ❑Y ®S NE❑UNK VEH. O AT CRASH O 99-U15-UNKNOWN CX>TOP03 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i 6 : Y COM VEH 0 0 1 C) ~ Hoffman Estates I L 60169 B 1 0 FIRST CONTACT 6 O7 _:,_Q:_® •irYes.See Sidebar U1 0 ZEQ16196 IL 2025 REAR TELEPHONE IL D 0 WDBJF65FXWA520856 Progressive ❑Y ®N U2 19 , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Shamoun.Steve 977338802 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu N DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NCv 0 DV /2 0 0 5 Nissan Frontier 2006 00-NONE O z "O DUE TO CRASH ❑ (� 2 0 13-UNDER CARRIAGE 6 I ©Ic 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraclion Value 9 U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 11:, 4 COM VEH ❑ ® CO FIRST CONTACT 12 7�� _,•.5 •If Yes.See Sidebar ~ 60110 0 1 0 80986LB IL 2025 I 0 Si) M IL D 0 1 N6AD07W26C444990 Statefarm ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Ramirez.Javier 0882416SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 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 1 09,23 ,2024 01 43 ®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 20 99 09,23 ,2024 01 44 ®PM 0 Construction >E R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Shamoun. Evelyn.S. 11-802-A 1500000275 09/23/2024 01 48 ®PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility AM t 2 El ARREST NAME 09/23 /2024 02 11 ®PM ElUnknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1500-Chew. Marie 501 275-Engelke 10 ,21 ,2024 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 } }----r___-; I I I _ combination):or more than pounds(example:truck ortruckrtrarler 1. Has a weight rating10 000i -< INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C N _ _ - } (example:shuttle or charter bus):or A 1 u 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 I rrm�nrwa transporter-usually a van type vehicle or passenger car):or w __ __ Not To Scale I } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. w for direct compensation(example:large van used for specific purpose):or __ __ + 7987N79Yete?St _ i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z ii _ ADDRESS 0 (D/) uma 0 CITY/STATE/ZIP g _r ® - i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 ---"-1 - USDOT NO. ILCC NO. m m XI Source of above z . IDOT PERMIT NO. WIDELOADo ❑Yes 0 No = TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m a 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 Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE