HomeMy WebLinkAbout2024-00065225 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 MO VU fl 11100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00065225 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l
® ❑ RELATED ®Y 0 N 10 12 2024 NAM ❑YES N NO U1 —<
S GIFFORD ST Elgin10:33
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
FT!MI N E S W FULTON ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED EN U1 Q
NAME(LAST,FIRST,M) Bridges. Raymone. D. 1 0 / yr 13-UNDERCARRIAGE 161 O�.-2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn
M 2 4 SYTM❑Y NSNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 76•TOP 3 *Distraction Value 5 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH 0 !� 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1
Z DQ26139 IL 2025 REAR
TELEPHONE
IL D 1 C4RJ FBG5KC583698 State Farm ❑Y ®N U2 13 , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2353371SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
g DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 KCv 0 Dv
/
1 9 9 7 Lexus ES250 1994 00-NONE 11_"j t2..--, DUE TO CRASH rg ❑ 2 x
o Yr 13-UNDER CARRIAGE 1 FIRE ❑ N U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istrac on Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 I( 4 COM VEH ❑ N U1 CO
FIRST CONTACT 3 7�. -5 •If Yes.See Sidebar
n ELGIN IL 60123 0 1 0 EU11260 IL 2025 I g Sn
Z
IL D JT8GK13T2R0070616 Safety Insurance ❑Y N N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Same 4138655-IL-PP-001 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT( (DOB1 (SEX) {SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 6 08 / M 12 3 B 1 0
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/ / #OCCS >
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 10,12 l2024 10 33 0 PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 0 41 2 10,12 ,2024 10 33 0 PM 0 Construction
R O 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ®AM 0 Maintenance U2
o ® 11 4 ARREST NAME Bridges. Raymone. D. 11-601 1504000413 10,12 l2024 10 36 ❑PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
25
r 2 ARREST NAME AM
T El ! ❑❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
1504-Real, Hilario 301 275-Engelke 11 ,26,2024 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.
r ----r••--, , I
® 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 -
i- }__-_r_-_-; I I. combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- r (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I. } } transporting employee In the course of their employment(example:employee X
i i transporter-usually a van type vehicle or passenger car):or w
L L____a Fufton?3t. � r ` 1 4. Is used ordesi natedtotrans rtbetween9and 15 passengers,including y- } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
f �
L L____a____� - once
— —
t } } I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0
D
I z n
CITY/STATE/ZIP 0
di. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
co I 0 0
, I I r- Not in Comm./Gout. Not in Comm./Other
-_---- - Not To Scale I - ; 0
• USDOT NO. ILCC NO. m
XI
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
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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 VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Bronze White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE