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HomeMy WebLinkAbout2024-00067965 , I III ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets Il ii III OII III 111111 11 lIOfl IHO I DI ID 11100010111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00359°109' u, 9 uz 1 1 4 1 Ui 2 U2 1 U199 U2 1 U1 99 U2 1 4 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY ill OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067965 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 KIMBALL ST ® ❑ Elgin RELATED ®Y ❑N 10 24 2024 06:41 ❑AM ❑YES ®No U1 .( PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W N SPRING ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 DI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FRONT TOWED U, O .0. / / Unknown Unknown 00-NONE ©' ..0..Dt DUE TO CRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� z DISTRACTED 0 El U2 2 m SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 I ❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value g ALGN .- r CITY PLATE NO. STATE YEAR POINT OF & . 6 4 COM VEH 0 ® 1 0 F UNKNOWN Unknown ❑Y ®N U2 I— m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 9 Same Unknown 1I— m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 99 0 ®DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑soy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Rizvi. Madiha 0 mo6 a 8 1 9 9 6 Mercedes-Beri2L450 2011 Do-NONE ;0 12 s REocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR Y C) E. 25 DUMBARTON OAKS PL F SYSTEM IN O ENGAGED O ® 16-TOP 3 -OTHER 9 ❑ MI ❑UNK VEH. AT CRASH 99-UNKNOWN & 4 •Distraction Value g U1 0 1 to H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST POINT COM VEH ❑ IN 6 7__L O,' byes,See Sidebar C ELGIN IL 60123 0 DD47148 IL 2024 REAR 0 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)814-9463 R210-5409-6783 IL D 0 4JGBF7BE2BA631043 Geico ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 RIZVI-ZEHRA 6087757925 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°®NR 25 DUMBARTON OAKS PL. ELGIN . IL.60123 (630)814-9463 Ut = (UNIT' (SEAT) (DOB( (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)1(TELEPHONE) (EMS( (HOSPITAL) n I I U2 996 r m #OCCS y / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El Y U2 Z N ® 11 1 10,24 ,2024 06 41 ®pm in a Work Zone? ®N DIRP co1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 C) T 2 0 28 99 ! , 0 PM El Construction * c' 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q 1 CO 11 1 ARREST NAME / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' ❑Utility o N ❑ ❑ SECTION CITATION NO. AM 30 2 ❑ ARREST NAME 10,24 /2024 07 40 ®PM 0 Unknown work zone type U1 1,1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 485-Quintana.Josue 102 334-Fries , , 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. F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS , J�r I I t 7 r A CMV is defined as any motor vehicle used to transport passengers or property and. Z j0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i ; 1 combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` i 1 d i - - -` ` r r r (example'.shuttle or charter bus)-or n S MEM4 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i } } itransporting employeesemployment(example employee `-----`----' nit Unit 1 in the course of their e e a � transporter-usually a van type vehicle or passenger car).or w i_____A____: : , : i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C fo ect ensation( xample. van used i i 5 r Is'rany vehicle usedtotransportla nehazardous for materialspecific (HAZMAT)purpose) that requires 11 O rn placarding(example placards will be any on the vehicle) 71 T. ♦ CARRIER NAME Z . I I l�mholi�st .. ADDRESS To I. N cn c) CITY/STATE/ZIP I I Not To Scale I MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other ' USDOT NO. ILCC NO. C , Source of above Z . IDOT PERMIT NO WIDELOAD? ❑Yes ❑No = ' TRAILER VIN 1 m CA LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m -Ti TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Red Black - 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE