HomeMy WebLinkAbout2024-00074505 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII DIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202412024-00074505 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
SUMMIT ST El In 03:39
® ❑ RELATED ®Y 0 N 11 25 2024 DAM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W N LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Egl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 9 /
Ford F150 2004 OD-NONE 11 6-A_, DUE TO CRASH ❑
13-UNDER CARRIAGE 10 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 4 rn
M 2 4 SY❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i1 6 4 COM VEH 0 j$J 1 O
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; _-5 *II Yes.See Sidebar U1
Z 3414691B IL 2024 . E
TELEPHONE
IL D 0 1 FTPW145X4KC09877 StateFarm ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0195636-SFP-13' 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑
1 9 yf 1 Chevrolet Equinox 2024 00-NONE ill 12..- , DUETO CRASH ❑ !1 2 x
o 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 I,,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_Os•_5 •If Yes.See Sidebar
n ELGIN IL 60120 0 1 0 EP70710 IL 2024 REAR
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IL D 0 3GNAXHEG9RL286006 American Family ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 175505890816-FPPA-IL BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (0081 (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 ® 11 4 11 !25 l2024 03 39 ®pm 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
0 2 03 99 ! ! 0 PM ❑Construction *
Z3 0 I!!I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
® 11 4 ARREST NAME
ZAMARRI PA.JUAN 11-601-Ax (W)455-309 / ! El PM
u1 0 CITATIONS ISSUED ❑PENDING Utilit SLMT
o
o N SECTION CITATION NO. ROAD CLEARANCE TIME Ely
T 2 0 ARREST NAME 11!25 l2024 03 39 ®PM El Unknown work zone type U1 0 AM 25
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 25
455 HallaE.Gabriel 201 ! , ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or 03
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
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
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LOCAL USE ONLY TRAILER VIN 2 m
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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
Red Black
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE