HomeMy WebLinkAbout2024-00063001 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
I01101100 M Hill
ill 11111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035:3098
u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00063001 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 10 02 2024 12,— ❑YES ®NO U1 -<
S LIBERTY ST Elgin mo /day/yr 04:36 ®PM FLOW CONDITION Ill
_
®15((1 !MI N E O W EASTVI EW St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
QUADRI. HAFEEZ. M. 1 0
yr 13-UNDER CARRIAGE IE
10 1 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 15-OTHER
99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a 4 COM VEH 0 ZgJ 2 O
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *lives.See Sidebar U1
Z AYESHA7 IL 2025 REAR
TELEPHONE
IL D 0 WBAEU33493PM57926 STATE FARM ❑Y ®N U2 Ill , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3314519SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 eu
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 NCv 0 DV
1 9 5 5 Kia Motors Colporento 2016 00-NONE 11_-1 12--_1 DUE TO CRASH ❑ C 2
o 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracllon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S ..,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
= ELGIN IL 60120 0 1 0 Y932722 IL 2025 REAR
n
IL D 0 SXYPGDA58GG073861 STATE FARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0865375SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (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 10(21 )024 04 36 ®pm 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
o"
2 28 18 ( ( 0 PM• 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME QUADRI. HAFEEZ. M. 11-601-Ax 433001470 / r El PM '
1 ® 1 1 1 ❑CITATIONS ISSUED PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit y
0 AM
t 2 ElARREST NAME 10 r 2) (024 04 36 ®PM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
433-Miracle. Matthew 302 10 ,22(2024 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 .
r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer >1.
i- -----r----ITo Scale 1 - INDICATE NORTH combination):or A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees in the course of their employment(example:employee P3
— — — transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
P- MEER Pe ( P 9 Pe or O
i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a placarding(example:placards will be isplayed on the vehicle).
2#
CARRIER NAME Z
L ADDRESS O
T.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate .5I I T I § ❑ Not in Comm./Govt. Not in Comm./Other
�------ --1 - USDOT NO. ILCC NO. rn
PCI
Source of above z
. m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red Maroon
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