HomeMy WebLinkAbout2024-00064240 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H II HII DIII
U II IID
HI hIll 1111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003581408
u, 1 U2 1 1 1 U1 2 U2 U, 1 1_12 U, 1 U2 1 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00064240 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
SOUTH ST Elgin
® ❑ RELATED ❑Y ®N 10 08 2024 ❑AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 12.40 ®PM FLOW CONDITION M
010�/MI NOS W LON DON DERRY Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 1 /
yr 2021 13-UNDER CARRIAGE tU l 2 FIRE ❑ ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 rn
F 2 SY is-OTHER
8 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 t6•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a 4 COM VEH 0 Ea 4 00
~ ELGIN I N I L 60124 B 1 0 FIRST CONTACT 12 7_: __5 *lI Yes.See Sidebar U1
Z EU62442 IL 2025 REAR
TELEPHONE
IL D 0 KM8K53AG8MU106231 GEICO ❑Y ®N U2 m
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Attaluri.Sudha 4096533494 1 1-
15 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr 12 _ C
o 13-UNDER CARRIAGE 10 I 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:-5 COM•I sVEH See •Sidebar❑ 0
C
CO
F` pEAR` C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTHI PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1ITELEPHONEI (EMS) (HOSPITAL) 0
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 1 3 City of Elgin BLACK LIGHT POLE DAMAGED 10/08 /2024 12 40 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 70
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
8.7 t 2 ❑ 30 150 DEXTER CT ELGIN IL 60120 15 99 1 / ❑AM ❑Construction F
z3 ❑ El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a GANGAVARAPU. RUKMINI 11-701 W244-1781 / ! PM
-, ARREST NAME ❑
ou 1 ❑ ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
t 2 ❑ ARREST NAME AM
7 / / pM El Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? ❑
244 Blomberg. Michael 801 272-Bajak / / ❑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 INDICATE NORTH comWnation)or XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
` `""f— ; Not To Scale] N - } } } transportingemployees in the course of their employment
pbyment(example:employee 73
transporter-usually a van type vehicle or passenger car):or CO
L L.___a__._3 „ 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. 'CD
I. } } for direct compensation(example:large van used for speific purose):or N
L L--_-a_ � F - I. � L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
- placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
I r ❑ 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 ❑No ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
71
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Whitew
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE