HomeMy WebLinkAbout2024-00065771 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 111111111111111110111111111111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E486
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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 2
ID NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) 0 B Injury and JorTow Due To Crash YR 202412024-00065771 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 7'1
N RANDALL RD El ❑
Elgin RELATED ®'' ❑N 10 14 2024 09:07 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W FOOTHILL
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O
tg oRNER ❑ PARKED ❑ERNERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
Mercedes-BerM L550 2013 00-NONE
FOR DAMAGED AREA(S) FRONT TOWED Ut O
NAME(LAST,FIRST,M) ,GEORGINA,J. mo 1 1 / day J yr 0 Q D DIJE TO CRASH ® 0 E13-UNDERCARRIAGE FIRE 0
IA
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED ® 0 U2 0 m
2647 LAUREN LN F ❑Y ®SNE❑UNK VEH. 0 SYTM ATCRASH 99-UUNKNOWN 916-TOP 3 ,Distraction Value 7 ALGN =
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W. CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH ❑ ® 1
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FIRST CONTACT 12 7_.i
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❑ 4JGDA7DBXDA262171 NA El ❑N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
GRANADOS, DELMIE NA 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
•o ❑Y ®N 2 RESPONDER 1420 CARLISLE ST,ALGONQUIN , IL,60102 VEHU GI
GI
®DRIVER ❑ PARKED 0 CRNERLESS 0 PED 0 PEDAL 0 EOUES 0 NUN ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
s O S / 2 9 /1 9 5 4 FOR DAMAGED AREA(S) TOWED CRASH Y N
NAME(LAST,FIRST,M) Baran, Bruce. E. mo day yr Buick Enclave 2012 00-NONE tt' 121.0 DUE o fffi 0 2XI
c 13-UNDER CARRIAGE j _ Z FIRE ❑ [2] U2 C
10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ IN SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 916-TOP® X
E 167 S LIBERTY ST M ❑Y MI N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 0
NT U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR I8T COONTACT 2 7. 16 •• •.5 C•UOM VEH See Sidebar IN to
H ELGIN IL 60120 B DN48486 IL 2025 REAk 0
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)429-1815 B650-0655-4153 IL D SGAKRCEDXCJ299783 AMERICAN FAMILY ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 0777-7986-05-24-fppa BAC 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
0 RESPONDER Same U1 =
(UNIT( i SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME 171 ADDRESS i((TELEPHONE) (EMS( (HOSPITAL)
Simona T Tzviatkova/ 900 THORNWOOD LN ,Algonquin,IL60102/ - 996 r
W 07 /20/1998 F (224)806 6258 U2 m
#OCCS y
U1 1
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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 ® 11 4 10/14 ,2024 09 07 ®pM in a Work Zone? ®N DIRP D
IN
PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1
2 ❑ 25 2 10,14 /2024 09 07 ®PM ❑Construction *
N 1 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
Q 1 ® 11 4 ARREST NAME ECONOMOS,GEORGINA,J. 11-306 51533-000155 10/14/2024 09 13 ®PM SLMT
o u ®CITATIONS ISSUED 0 PENDING •
TIME < 0 Utility
o NSECTION CITATION NO. ROAD CLEARANCE AM 45
2 0 ARREST NAME ECO N OMOS,G EORG I NA.J. 3-707 S1533-000154 10(14 /2024 09 43 ®PM 0 Unknown work zone type U1
T •
• OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1533-Ruiz.Jose 602 397-Jones 11 , 12/2024 09 00 0 PM Workers present? °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
; _r } A CMV is defined as any motor vehicle used to transport passengers or property and.
D
I I 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
` 1 ; ' 1 I I ` r INDICATE NORTH combination) or -1
Not To Scala j i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', 1 0 I I -t . r r r (example'.shuttle or charter bus)-or 0
t------;-----1 I -t t } - t transporting employeeed to sl5 or fewer in the course their employrs and ment(example�emact ployeerier OM
tr
-usually a van
vehicle or
ca
�____A____: : , rooeaiT(te i r i 4a Is usedror designated to trransport between 9 agdr 15rpassengers,including the driver, N
for direct compensation(example:large van used for specific purpose).or O
L____ ____; , — —
® �"d2 — — — — — i 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
UnM 2
I es�M'� _ placarding(example placards will be displayed on the vehicle) M
I w CARRIER NAME Z
' I i
ADDRESS0
N
I I •
CITY/STATE/ZIP
srdel7Rd. C
: - MOTOR CARR ID ❑ Interstate ❑ Intrastate -
r I 0 Not in Comm./Govt. ❑ Not in Comm./Other Q
C
USDOT NO. ILCC NO.
, Source of above Z
. own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown g
Did Carrier Safety Regulations(MCS)violation contribute to the crash% 0❑ Yes No ❑ Unknown
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
Form Number 0
rn
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 >10:' m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft N
Black Gray
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
Redmons/Impound Lot Garage 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