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HomeMy WebLinkAbout2024-00072263 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0110 0000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003628858 u, 1 U21 3 4 1 U, 2 U2 1 U, 1 1_12 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00072263 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 11 14 2024 ®AM ❑YES ®NO U1 -< N STATE ST Elgin11:37 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m 0 !MI N E S W BigTimber Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 6 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O (i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 0 5 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4_5 *II Yes.See Sidebar U1 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7 Z Wheeling IL 60090 0 1 0 Q103495 IL 2025 I , TELEPHONE IL D 0 ZACCJ BBT1 FPC26824 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Airlift 99 9 Same 0346832SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 c p; DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv /2 0 0 0 Ford Econoline E450 2019 00-NONE 11 FOR 12--_, DUE TO CRASH ❑ ❑ 21 73 omo Yr _ 13-UNDERCARRIAGE ta;I 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S I 6 .!.,_4 COM VEH ❑ ® Ut W FIRST CONTACT 6 7 -�-•_5 •(ryes.See Sidebar C Z SOUTH ELGIN IL 60177 0 1 0 164157F IL 2025 FIRST Si)0 D IL D 0 1 FDXE4FS4KDC65172 The Continental Ins Co ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Enterprise FM 7094185361 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 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 0 Y U2 Z N 1 ® 11 1 co 11 ,14 /2024 11 38 ®❑PM AM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 28 99 + ! ❑PM• ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 a1El 11 1 ARREST NAME Dominguez. Miguel.A. 11-601-Ax 4950000423 / / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility t 2 ❑ 45 ARREST NAME AM c- T / / ❑❑PM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 495-Sjodir.Jacob 501 404-Duffy 12 / 17/2024 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•---, , 0 ; 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 - ` ` ' ' u.er • INDICATE NORTH combination):or —I �^.�, 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C a: (example:shuttle or charter bus):or 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O tlesg pa 9 pe byI I- I- -A- -•i i - } } } transporting employees in the course of their employment(example:employee transporter usually a van type vehicle or passenger car).or w __ • _ 4. Is used or designated to transport between 9 and 15 passengers,including (I) } } for direct com nsation exam I lar a van used fors cific ur mdudi the driver, Pe ( P 9 Pe p pose):or O L L.__-a..... Ontlfl - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ' placarding(example:placards will be displayed on the vehicle). ;p —I CARRIER NAME Z BigITlmb.r?R.d / ` ` O ADDRESS - - - - - - - ( CCITY/STATE/ZIPng MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. Not in Comm./Other Not To Scale ( O 0 USDOT NO. ILCC NO. C XI Source of above Z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 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 VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v 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. Z White White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE