HomeMy WebLinkAbout2024-00067735 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111111111111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003593111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY N OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00067735 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mS LIBERTY ST Elgin 05:33
® ❑ RELATED ®Y 0 N 10 23 2024 ❑AM ❑YES ®No u1 -<
_ _ g PRIVATE mo /day/yr NPM FLOW CONDITION MFT!MI N E S W LAUREL ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NIA/ 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 0 0
T FOR DAMAGEDAREA(S) FROM TOWED U1 0
NAME(LAST,FIRST,M)
BUKRABA.JUSTYNA mo /1 9 8 5 Ford Explorer 2021 00-NONE 0• O" DUE TO CRASH ® El
-UNDER CARRIAGE 10 1 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 rn
F 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 0 1 n
I� _�FIRST CONTACT 12 7_ ,__5 *IIYes.See Sidebar U1 0
Z STREAMWOOD IL 60107 0 1 0 EJ58707 IL 2025 REAR
TELEPHONE
IL D 0 1 FMSK8DH6MGB00405 MERCURY INSURANCE ❑Y ®N U2 I''I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 BUKRABA. MAREK.W. ILAP0000045572 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAv 0 KCV 0 DV
/2 0 0 5 Honda Civic 2019 00-NONE ,i_"i Qj O DUE CRASH ❑ 2
0 13-UNDER CARRIAGE 10) I: 2 FIRE ❑ N U2 C
c
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOR®
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraellon Value 9 0
POINT OF 8 i1 1 CO
4 COM VEH ❑ N U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 1 Y _, _5 • C
ELGIN IL 60120 0 1 0 CB37058 IL 2025 REARIfYes,See Sidebar 0
IL D 0 SHHFK7H3OKU213674 STATE FARM ❑Y N N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Perez. Marvin.A. 0861087-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 4 08 /
/ / UI 2 :A
D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 N 11 4 10/23 /2024 05 33 ®pm in a Work Zone? ®N DIRP co
1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
T
o",
2 ❑ 2 28 / / ❑PM• ❑Construction
Z3 ❑ N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 6
a BUKRABA.JUSTYNA 11-901-A 1542-000018 / / PM '
-' 1 N 11 4 ARREST NAME ❑
o u CITATIONS ISSUED 0 PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME • ❑
t 2 El ARREST NAME 10/23 /2024 05 38 ®PM El Unknown work zone type U1 El AM 30
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1 542 Chafe. Ethan 301 334 Fries 11 / 19,2024 09 00 ❑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
0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} } ' ' r INDICATE NORTH combination):or p3
Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ i. e. (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
J �
` A—
transporter-usually a van type vehicle or passenger car):or w
C
__ __ - I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or
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-D
L L____a____. c"" ' — _ t 5 anyIs any vehicle used to transport hazardous material(HAZMAT)that requires
Fri)$ ,:,N� � placarding(example:placards will be isplayed on the vehicle). XI
—• t Paoli CARRIER NAME Z
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ADDRESS 0
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CITY/STATE/ZIPC
MOTOR CARR.ID ❑ Ita ❑
I I T I ❑ Notnters in Cotemm./GaA. Not inIntrastate Comm./Other
-"-----'-1 - USDOT NO. ILCC NO. m
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Source of above z
. Form Number m
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
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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
Blue Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE