HomeMy WebLinkAbout2024-00070625 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 4 Sheets 01111101111 101101100 IR 101111111110 II
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY MOM 1,398
u, 1 U21 1 1 1 U1 4 U2 1 u, 1 U2 1 U, 1 U2 1 5 11 u1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 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 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00070625 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 11 06 2024 ®AM El YES El NO U1 -<
168 US ROUTE 20 HWY Elgin PRIVATE mo /day/yr 06:09 ❑PM FLOW CONDITION m
�0(y� ® COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn
!MI N E SState St WITH VEHICLES INVLD DO
U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 Peoa. 0 EWES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 4 /
yr 13-UNDER CARRIAGE 10:) 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 rn
M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 5 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Vatuc
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4,.4 COM VEH 0 181 1 0
F.
Elgin I L 60124 0 1 0 FIRST CONTACT 12 7_; _5 *IIYes.See Sidebar U1
Z 9 Q487195 IL 2024 REAR
TELEPHONE
IL B 7 1 G 1 ZW53166F280402 USAA ❑Y ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 011290492C 7101 5 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 3 2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 i v 0 Dv
yr 13-UNDER CARRIAGE 101 I.. 2 FIRE 0 El U2 C
F 2 4 ❑Y El
IN ENGAGED 15-OTHER 9 16-TOP 3 3
❑N UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
POINT OF s iI 4 COM VEH D ® Ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - all.._
FIRST CONTACT 6 Y__{_O ._5 •IfYes.See Sidebar
= Algonquin IL 60102 B 1 0 CC61885 IL 2025 REAR 0 C
IL D 5J6RW2H5OLL011479 American Family ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Downing, Kevin,C. 11882821264FPPAIL BAC
E
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)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 11 ,61 /024 06 09 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 ❑ 28 41 11/61 /024 06 10 ❑PM ❑Construction *
4
R O 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
J ®AM ❑Maintenance U2
- ®a, ARREST NAME Composano, Demetrius, M. 11-601 298001149 11/61 /024 06 16 ❑PM
oSLMT
U 1 11 1 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
Ti 2 El1 1 1 ARREST NAME Egeh, Liban, R. 3-707 298001150 11/61 /024 07 30 MPM ❑Unknown work zone type U1 55
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 55
298-Lopez, Mirko 701 272-Bajak 12 , 91 /024 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 truck trailer -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
X
- ------I----; - transportingdgemployeeo slIn the course of 5 or fewer he r emplrs oyment(example:employee a contract ner X
® } r } transporter-usually a van type vehicle or passenger car): r w
C
L I-----I-----I ri Not vb&sly I - . . . •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
no.dvm for direct compensation(example:large van used for specific purpose):or to
L _ a_ . — i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
I.
�J placarding P placards P Y )
Wcardi (example: will be displayed ed on the vehicle :0
CARRIER NAME Z
ADDRESS 0
V)
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----Y----1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Silver Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE