HomeMy WebLinkAbout2024-00070873 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets HUI III 0 IftIl
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00070873 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED ®Y 0 N 11 07 2024 ®AM ❑YES ®NO U1
RANDALL RD Elgin07:32
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 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 0 C)
0 2 /
yr
Kia Motors Co Itos 2022 00-NONE „ DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 i 12 ly 2- FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 14 U2 0 m
M 2 8
❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP
�3 * _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_:iL 6 ii,4 COM VEH 0 El 1 0
F. FIRST CONTACT 2 7_ —_;__-5 *Irves.See Sidebar U1
Z Geneva IL 60134 B 1 0 ARSNLG1 IL 2025 REAR
TELEPHONE
IL D KNDETCA28N7256254 Unknown ❑v ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
South Elgin Fire Same Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
.o Other ❑Y El 3 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑NMv 0 Ncv ❑DV
!1 9 yf 0 Ford Escape 2018 00-NONE i1_"j Q�,-_, DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C
il
F 2 8 ❑
SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑Y ❑N UNK VEH. AT CRASH 99-UNKNOWN `Oistrac( n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-il 6 1:,-4 C..OM ❑ ® U1 CO
FIRST CONTACT 12 7� .5 •IfYes.See Sidebar
F-
. . E LG I N I L 60123 B 1 0 AF39700 I L 2025 RFJ 0
IL D 1 FMCU9GD9JUD16260 Encompass ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire Same 2024299318 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND Y ❑El N 3 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 4 11 r 07 r2024 07 32 El PM in a Work Zone? NJ DIRP D
1 IT PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
0
2 ❑ 2 28 ! ! ❑PM• 0 Construction *
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Gonzalez, Noe 3-707 298001153 r ! ❑PM SLMT
ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
o N DI AM 50
r 2 0 ARREST NAME Gonzalez. Noe 11-902 29800115 r r PM 0 Unknown work zone type U1
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 801 272-Bajak r r ❑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 -<
c ` '' -' r INDICATE NORTH combination):or .Z-1
• BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
( r I y I I (example:shuttle or charter bus):or 0
L A J 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
rter-
< <.___a____� —N� •4alsuosedordestlnatedtotrans vehicle
rtbetween9andr15r) C
ssen rs,including[hedriver, to
I , — — I. } } } for direct compensation(examp large van used for specific purpose):or
t unes
1 O
L _a _ Not To Scale i. < i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
renarrnea. r placarding(example:placards will be displayed on the vehicle). ;p
—1
— — CARRIER NAME Z
ADDRESS 0
I
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Yellow Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE