HomeMy WebLinkAbout2024-00068724 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110110 11 III 10 11100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003604249
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00068724 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y 0 N 10 28 2024 ❑AM ❑YES ®NO U1 -<
N SPRING ST Elgin12:04
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W KI M BALL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 03 n
0 3 /
yr 13-UNDER CARRIAGE } : 2 FIRE ❑ al <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ® 0 U2 m
M 2 SYTHER
4 ❑Y ONM❑UNK VEH. O AT CRASH IN ENGAGED O 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL S 4 COM VEH 0 j$J 1 0
H 1- HAMPSHIRE IL 60140 0 1 0 FIRST CONTACT 12 r ; __5 *II Yes.See Sidebar U1
Z1153443B IL 2025 REAR
TELEPHONE
IL D 0 1GCEC14X64Z233375 KEMPER El ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 12A0001219068 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
!1 9$9 Chrysler 300 2020' 00-NONE ,01112 ._1 DUE FIREOCRASH 0 ® U2 2 C
.. 13-UNDER CARRIAGE III
c
F 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN O Oistracti n Value 9
U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _�J;,•
5
�/ 4 COM VEH_, • 0 ®
Z CARPENTERSVILLE FIRST CONTACT 2 7 _5 (ryes,See Si CO
debar IL 60110 B 1 0 EJ46397 IL 2025 REAR
D
IL D 0 2C3CCABG5LH131384 PROGRESSIVE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 972802335 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER NJ N U1 =
(UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 10/28 l2024 12 04 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 25 2 10/28 /2024 12 05 ®PM El Construction >E
<ov O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM 0 Maintenance U2
-o1Ela, ARREST NAME Abundes-Cuevas.J. R. 11-306 1543000010 10/28/2024 12 08 ®PM SLMT
u 11 1 •ISI CITATIONS ISSUED 0 PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME
AM, ❑Utility
t 2 El ARREST NAME Abundes-Cuevas.J. R. 6-101 1543000011 10/28 /2024 12 40 0 PM El Unknown work zone type U1 30
2 2 3 El OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1543-Sturgeon. Kyle 102 272-Bajak 11 /26/2024 01 30 ®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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
r ` --I -' r INDICATE NORTH combination):or —I
L BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} IN SPRING srl---0 \\ } r r r (example:shuttle or charter bus):or 0
II °'I' •4,r 3 Is tl ned t car 5 fewer ers a o r tetl contra car r esg o ry 1 or passeng ntl pea by a ct ne O
1 I Nay'+o r, } } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; ® GO" - •} } } 4. Is used or designated to transport between 9 and 15
assen including the driver. C
Q fr _ _ _ _ for direct compensation(example:large van used fors specific purpose):or O
4; '
L L____a____. o A 8 t i , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
8 placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
�� _ __ ADDRESS 0w
p
CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
'
. ❑ Yes 0 No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Red White
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE