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HomeMy WebLinkAbout2024-00073631 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 IIIIII IIIII I I IIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XoOa638524 u, 1 U21 2 4 3 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRAP/ ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash 0 AMENDED YR 2024I 2024-00073631 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1 S MELROSE AVE Elgin07:43 ® ❑ RELATED ®Y 0 N 11 21 2024 ®AM ❑YES El NO U1 -< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m FT!MI N E S W MEYERST COUNTY PROPERTY ❑Y Ill N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 02 ! yr Meunekithirath. Ko Toyota Sienna 00-NONE ©, • Q 0 DUE TOCRASH ® El13-UNDER CARRIAGE 10 I 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ 0 U2 0 NI m M 2 4 SYTM❑Y ®S NE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i1 6 �i,4 COM VEH ❑ El 1 0 ELGIN IL 60123 B 1 0 FIRST CONTACT 11 7_;{ __5 *ll Yes.See Sidebar U1 Z CY73178 IL 2025 REAR TELEPHONE IL D 0 5TDYK3DC7BS036982 STATE FARM ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Elgin Fire 99 9 Same 1090883-SFP-13 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ElN 2 0 ��, g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 l uv 0 NOV 0 DV yr Q 2 �1 0 13-UNDER CARRIAGE 10 j ©( 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 8 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i1 6 1I COM VEH D ® U1 IN FIRST CONTACT 1 Y _,__5 •IfYes,See Sidebar — Elgin IL 60123 0 1 0 CM86571 IL 2025 I 0 Si)c D IL D 0 YV1CN592651136399 STATE FARM ❑Y ®N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 ZURITA. ERIZEL. E. 3388527-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP U1 = (UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 6 02 / :A / / UI 2 m / / 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 4 11 ,21 ,2024 07 43 ®❑PM in a Work Zone? ®N DIRP co 1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 2 0 18 1 2 18 11,21 /2024 07 49pM 0 • ❑Construction >E R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 3 ®AM ❑Maintenance U2 oEl 11 4 ARREST NAME Meunekithirath. Ko 11-901-A S1542-000032 1 1,21 /2024 07 53 ❑pM SLMT N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility AM U1 30 T 2 ❑ ARREST NAME 1 1/21 /2024 09 25 M PM ❑Unknown work zone type 2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1542 Chafe. Ethan sot 275-Engelke 12 , 17,2024 09 00 ❑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 ■ r I I. ADDITIONAL UNITS FORMS. r -- r••--, , ■ Unit 3 ■ A CMV is defined as any motor vehicle used to transport passengers or property and: Z ■ (Parked Cer) ■ 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -< i- }--_-r----; ■ War ■ - INDICATE NORTH combination):or p3 ■ --' ■ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } : `. 47,4''— : - i. e. r r (example:shuttle or charter bus):or 0 ■ ■ 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 . 7 } .} } transporting employee In the course of their employment(example:employee I- < A ' ■ ■ transporter-usually a van type vehicle or passenger car):or CD `" .-_-' Nof To Scale •� `"�-"' l ■ - 4. Is used or desi nated to trans rt between 9 and 15 ssen rs,including the driver, N 1 ■ 8.1; rl` , q } } } • for direct compensation(example:large van used for specific purpose):or O L L-. ..i.. . ■■■■■ c + fink 1 i. < < L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m (Initial Creah ■■ placardig(example:placards will be isplayed on the vehicle). XI `i D rwl ` t I - CARRIER NAME �; - ADDRESS D G w ■■■■■ I ■■■■ CITY/STATE/ZIP 0 ■ : MOTOR CARR.ID 0 Interstate 0 Intrastate 5 1 1 T 1 ■ I ■ ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 'Y I ■ - i" USDOT NO. ILCC NO. C XI Source of above z . 0 Yes 0 No ❑ Unknown A 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 to LOCAL USE ONLY TRAILER VIN 2 m 0 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 Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE