HomeMy WebLinkAbout2024-00066044 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 OIl III I IIII lull
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003539551
u, U2 1 Ut 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
$
0 NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00066044 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I
RT20 WB ®gin ID
❑Y coN 10 16 2024 06:50 ®AM El ®No ut • ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
1 0(]� 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U)
® �Cl/MI NOS W S.State St 'WITH VEHICLES INVLD ❑ STOPPED U2 —1
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0
tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 4 / 2 0 /1 9 9 9 FOR DAMAGED AREA(S) FRONT TOWED U1
, Pedro Toyota Corolla 2013 00-NONE „ i , DUETOCRASH ❑
NAME(LAST,FIRST,M) mo day yr Q
13-UNDERCARRIAGE �D I 2 FIRE 0 1l <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m
1550 MULBERRY LN D M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 I
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN
r CITY PLATE NO. STATE YEAR POINT OF iI O Ji C.OM VEH 0 El 1 0
~
2T1 BU4EE8DC076103 American Alliance ❑Y ®N U2 43 . m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
3 Same ILAA091703300 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE.ZIP PHONE NUMBER r
'' RESPONDER Same VEHU
L ❑Y ❑N 2 t7
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
5 O 8 / 1 5 /2 0 0 0 FOR DAMAGED AREA(S) FRONT TOWED TOCRASH Y N —1
NAME(LAST,FIRST,M) Romero. Karina mo day yr Hyundai Sonata 2015 00-NONE ,t 12 , fffi 0 2 Xi
v t3-UNDER CARRIAGE 10 j 2 FIRE ❑ 21 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR C)
SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3
E. 324 WASHINGTON ST F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I I n,, 4 C
ll U1
F FIRST CONTACT 6 7 t -S CIOMes,See Sidebar ® C
ELGIN IL 60123 B DT89211H IL 2025 REAR
0 (n
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(630)715-7010 R560-5000-0832 IL D 5NPE34AF1 FH229287 America Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same I LAA097910300 Bnc ' 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
❑Y N Same U1 _
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
I I U2 996 1-
m
/ - - '#OCCS D
/ /• U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z
N 1 oil 1 10/16 /2024 06 50 ❑pM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U, 7 C)
T 2 0 03 03
! / 0 PM ❑Construction 7 *
r�1A T 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
•
Q El 11 1 ARREST NAME Acabal Coc, Pedro 11-710-A 1540-007 / / El PM SLMT
o U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
p N AM 55
2 0 ARREST NAME Lukasik.Anthony-j. 11-710-A 1540-006 r / 8 PM 0 Unknown work zone type Ut
T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑AM Workers present? El Y 55
2 2 3 0
1540-Allah. Muhammad 1 0 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.
0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
; _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
Tx
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I ; i combination).or —I
• INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
-( I d i f� -t ` r r r (example'.shuttle or charter bus)-or n
iiiirmW Xi ; ; i ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
f.-----;-----� 4 1 -f } - t transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or CO
'____A____- : i prnp : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u)
for direct compensation(example:large van used for specific purpose).or O
11
L____-�____1 i; , - i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
.�+ placarding(example placards will be displayed on the vehicle) 71
unit:--wu 1—vnt a
CARRIER NAME Z
t ADDRESS 0
N
. Not Tb Scale J -
O
CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r ,
USDOT NO. ILCC NO.
• , Source of above Z
. ❑ 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 ❑ No
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
Form Number 0
M
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Black White
-
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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE