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HomeMy WebLinkAbout2024-00067347 , l II l ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets ii ii Ill DIII Ifi 1In ll 111111111111 11111011111 11101111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E464 u, 1 U21 3 4 1 U, 8 U2 1 U, 1 U2 1 Ut 1 U2 1 4 12 U1 13 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500El NOT ON S ®ON SCENE 3 VEHICLE/PROPERTY ElOVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00067347 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m N RANDALL RD El ❑ Elgin RELATED ®Y ❑N 10 21 2024 07:08 ❑AM ® ❑YES NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 co EP ®/MI N E OS W Foothill Rd 'WITH VEHICLES INVLD 0 STOPPED U2 —1 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGED AREA(S) FRONT TOWED Ut NAME(LAST,FIRST,M) y mo day yr O ba,A. 1 1 / 1 3 /2 0 0 5 Toyota Camry 2015 00-NONE „ 12 1 , DUE TO CRASH 0 13-UNDERCARRIAGE FIRE 0 fzi SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® U2 4 m 10 2 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 1325 W LINCOLN HWY A214 M / DY ®N DUNK VEH. AT CRASH 99-UNKNOWN 4 'Distraction Value ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF O 1, 6 COM VEH ❑ ® 1 0 F FIRST CONTACT 8 7O.ri—'�5 .Irves,See Sidebar U1 0 Z 4T1 BD1 FKXFU144132 United Security Health ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a AHMED. KHALIED. M. US1884731-02 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r o RESPONDER N 1325 W LINCOLN HWY A214. DEKALB . IL.60115 (312)383-4170 VEHU ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) LINCHESKY,CRYSTAL. L. 0 9 Oa 1 9 8 2 mo d yr Jeep(after 19S8)sngler 2022 00-NONE 11: 12 I°O DUE TO CRASH ❑ ® 2 xi a 19(13-UNDER CARRIAGE 2 FIRE ❑ ® U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPCA C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X a` 1205 N LANCASTER CIR F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF NTACT 1 T_16 1_5 C•IOMes Bee SidebaH r Ig1 U1 to C Z SOUTH ELGIN IL 60177 0 DG71674 IL 2025 F> 0 (n D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)965-6865 L522-1128-2851 IL D 0 1 C4HJXEG5NW149104 Geico ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I IALIBERTE,Gary, R. 6084-54-56-38 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 1205 N LANCASTER CIR.SOUTH ELGIN . IL,60177 (708)707-0868 U1 = (UNIT) (SEAT) (DOS) (SEX, ,(SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'/-(ADDRESS)/(TELEPHONE} (EMS) (HOSPITAL) 1 6 03 /05/2023 M 12 4 0 1 0 Musa K. Ahmed/1325 W LINCOLN HWY B406,Dekalb-IL-60115 Refused 996 1 (312)383-2520 , U2 m 1 5 09 /29/1988 F 2 4 0 1 0 ISLAM A. AHMED/1325 W LINCOLN HWY B406,Dekalb.IL-60115 Refused #OCCS D (312)383-2520 _ 73 1 4 08 /1 0/1978 F 2 4 0 1 0 ISRA A. ALI/1325 W LINCOLN HWY 214A,Dekalb,IL,60115 Refused UI 5 m (779)777-4608 1 3 08 /1 8/1983 M 2 4 0 1 0 ALRASHEED G. MOHAMED/1325 W LINCOLN HWY A403-Dekalb.IL.60115 Refused O (815)650-6356 U2 2 Z EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y N ® 11 1 co 10/21 /2024 07 31 to in a Work Zone? El DIRP D 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME I1 YES check one below: U1 1 C) T 2 ❑ 15 26 ID AM ! I 0 PM El Construction * N 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 El AM El Maintenance U2 Q ® 11 1 ARREST NAME / / 0 PM SLMT o U CITATIONS ISSUEDPENDING ROAD CLEARANCE TIME ' ❑Utility o N ❑ 0 SECTION CITATION NO. AM 45 2 0 ARREST NAME 10/21 /2024 07 59 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 476-Ramos,Clarissa 602 334-Fries / / ❑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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I . 0" ADDITIONAL UNITS FORMS ' } 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 Z ' r • ; i ; i- r r , , i INDICATE NORTH combination).or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! i. L ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 • CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, i r r r r r----, r - DO ILCC NO. m U N XI , Source of above Z . 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 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 Black - 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 DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE