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HomeMy WebLinkAbout2024-00069580 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H iinii IIIIII 01100 11111 nil ii 1111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003610975 u, 1 U21 1 1 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 4 u2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00069580 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 ® ❑ RELATED PRIVATE ❑Y ®N 11 01 2024 ®AM ❑YES ®NO U1 -< BLUFF CITY BLVD Elgin mo /day/yr 07:31 ❑PM FLOW CONDITION Ill ®15((1 !MI N E S © St Charles St COUNTY PROPERTY ❑Y Igl N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl) Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / RX350 2017 00-NONE ©1 O' , DUE TO CRASH ® ❑ O NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE I FIRE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 ❑ N DISTRACTED 0 0 U2 2 m F 2 SY is-OTHER 5 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 �i COM VEH 0 Ea 1 0 ELGIN IL 60120 B 1 0 FIRST CONTACT 11 7_: __5 *IfYes.SeeSidebar U1 Z EN24818 IL 2025 REAR TELEPHONE IL D 2T2BZMCA3HC067750 STATE FARM ❑Y ®N U2 I-- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 1 99 9 Same 1739539-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 N4v 0 NOV 0 DV 1 9 yf 7 Ford F150 Do-NONE ,._"1 Qj O DUETOCRASH rg ❑ 2 13-UNDER CARRIAGE I FIRE ❑ N U2 F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracJDn Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i_i, COM VEH El U1 CO H FIRST CONTACT 1 Y _, _5 •(ryes.See Sidebar ELGINREAR C M IL 60120 B 1 0 3767055B IL 2025 IL D 1 FTEW1 E80FKD14883 KEMPER ❑Y N N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 1 99 9 Same 12RA000035411 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 11 ,01 /2024 07 31 ®❑AM 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 2 15 11 r 01 ,2024 07 35 ❑PM 0 Construction * 4 <w 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ®AM 0 Maintenance U2 -a, ARREST NAME LUPIAN. MARIA.G. 11-906 435000689 11 r 01 r2024 07 40 ❑PM SLMT I El 11 1 ❑CITATIONS ISSUED PENDING Utility N SECTION CITATION NO. ROAD CLEARANCE TIME o 0 AM u, 25 r 2 El ARREST NAME 1 1 r 01 ,2024 08 30 [0 PM 0 Unknown work zone type 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AZ Workers present? ❑Y 25 435-Mahan. David 401 275-Engelke 12 ,02,2024 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 i. <-- _ -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L i.___-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt --I CARRIER NAME Z i. ADDRESS 0 CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . 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'; 0 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Black 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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE