HomeMy WebLinkAbout2024-00069873 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003610335
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202412024-00069873 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 11 02 2024 ❑AM ❑YES ®NO U1 -<
LAWRENCE AVE Elgin04:28
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 16 '
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —1
lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
01 FOR DAMAGEDAREA(S) FRONT TOWED U1 O
MercuryMariner 2005 00-NONE OUETOCRASH ❑ VI
NAME(LAST,FIRST.M) Youkhanna.Younan. N. mo / ! yr �. 12
13-UNDER CARRIAGE D} I! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 0 rr1
M 2 SYTM IN ENGAGETHER
4 ❑Y ®SNE EDUNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 016-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH 0 0 1 n
F. FIRST CONTACT 10 7 _� ,__5 *If Yes.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 AJ91440 IL 2025 RFAR
TELEPHONE
IL D 4M2CU56145DJ28556 Safeway Insurance Company ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3150858-I L-PP-003. 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
e. RESPONDER 73
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Refused 0 Y ❑ N 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑row 0 i v ❑Dv
yr 12
o 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-Top
❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iII 6 1Y 4 COM VEH ❑ ® U1 W
F,,, FIRST CONTACT 2 7----,--5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 712902AM IL 2025 REAR 0 N
Z
IL B 1 FDUF4HTOFEC83352 Alliant Insurance Service ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire City of Elgin.City.o. 8109160P901 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 09 / M 2 3 0 1
m
/ / #OCCS D
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,03 l2024 04 28 ®AM 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 5 n
T
O 2 ❑ 75 2 I ! ❑PM ❑Construction *
R5
3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Youkhanna.Younan. N. 11-907-A W487000496 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
35
r 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
487-Heal. Kayla 601 - r ! El 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
I 1 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- -----------; 8/8?N'8tate78t I - combination):or —I
INDICATE NORTH p1
` - 1 i. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I
(example:shuttle or charter bus):or
5 or fewer
L -----;----; �/a7N•steta?st - } } } transportinggemployees ino the course of he r emplrs oyment example:employee a contract
X
_ transporter-usuallyp a van type vehicle or passenger car):or CO
L L.___a____� s � S. } } } •4. Is used or designated to transport between 9 and 15 passengers,indudingthe driver, C
wra+I rorenw "r for direct compensation(example:large van used for specific purpose):or O
_ -D
i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
I _ . . . . placarding(example:placards will be displayed on the vehicle). XI
— EIB?KIrrben?at - _I
— CARRIER NAME Z
t _ ADDRESS 0
r I- I
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I Not To Scale f 0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes ❑ No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No ❑ Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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 VIM 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Red
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE