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HomeMy WebLinkAbout2024-00073139 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I01101100 11111 II I 10 III II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003630469 u, 1 U21 13 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 5 12 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2024I 2024-00073139 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n RT20 WB Elgin® ❑ RELATED ❑Y ®N 11 18 2024 06:56 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr NPM FLOW CONDITION m FT!MI N E S W VILLA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ❑ Cook HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0NAME(LAST,FIRST,M) Henry. Deshauna. L. mo yr g Land Rover Ran a Rover 2013 00-NONE OUE TO CRASH ❑ VI ©1. 12 - 13-UNDER CARRIAGE } I! 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 3 M F 2 SYTM IN ENGAGETHER 4 ❑Y NSNE DUNK VEH. 0 AT CRASH 0 99-Uis-UNKNOWN 016-TOP 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH ❑ Ea 1 0 ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 10 7 ; _5 *II Yes.See Sidebar U1 Z CS87604 IL 2025 REAR TELEPHONE IL D SALGS2EF1 DA122747 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 12RA000019128 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ® N 2 .41 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV /1 9 9 7 Toyota Camry 2007 00-NONE 1("j 12..`1 DUE TO CRASH rg ❑ 2 x O 13-UNDER CARRIAGE 10'i 2 FIRE ❑ ® U2 C Ti F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 91,16-TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6- 1. 6 jl 4 COM VEH ❑ N U1 CO FIRST CONTACT 4 7� ,SOS •byes,See Sidebar ELGIN IL 60123 B 1 0 EB92296 IL 2025 IL D 4T1 BE46K67U650542 American Family ❑Y N N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Diaz. Maritza 215710940259FPPAIL BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJ) (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) 2 4 12 / ' D / / 3 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 11 ,18 ,2024 06 56 0 AM in a Work Zone? ®N DIRP co 1 I 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 2 20 11,18 /2024 06 57 mi PM ❑Construction * R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Henry. Deshauna. L. 11-708 1532-000346 11,18/2024 07 01 ®pM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility 0 AM r 2 0 37 3 ARREST NAME 1 1/18 /2024 08 00 0 PM 0 Unknown work zone type U1 55 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 55 1532-Hernandez. Daniel 302 12 , 10/2024 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••--, , ; 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 -< c ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or 1 i 7 3. Is designed to carry 15 or fewer passengers and operated �rated a contract carrier O I- I- -A- ----J. ��Stele ! - } } } transporting employees in the course of their employment(example:employee � X - transporter-usually a van type vehicle or passenger car):or w L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; , ___ - } } g po pafic p rs,includi the driver, for direct compensation(example:large van used for specific purpose):or L L--_-a-.... a r l. i. i L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires M — placarding(example:placards will be displayed on the vehicle). XI D 1 CARRIER NAME Z .. '°P,+epe ADDRESS 0 C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. m XI Source of above z . IDOT PERMIT NO. WIDELOAD"; ❑Yes 0 No = TRAILER VIN 1 m co 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 Black Gray 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE