HomeMy WebLinkAbout2024-00074925 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003643628
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
El AMENDED
YR 202412024-00074925 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 11 27 2024 ❑AM ❑YES ®NO U1 -<
COOPER AVE Elgin mo /day/yr 12:48 ®PM FLOW CONDITION III_
®15 Or MI N E 0 W COOPER Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 0)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
RUIZ, DEVIAN.A. 0 2 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 3 I<T1
M 2 4 ®Y ❑SNEM❑UNK VEH. 4 AT CRASH IN ENGAGED1 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, �--it a �i_;_ COM VEH 0 0 1 0
f. FIRST CONTACT 11 7_; _5 *II Yes.See Sidebar U1
Z CRYSTAL LAKE IL 60014 0 1 0 G102019X IL 2028 REAR
TELEPHONE
IL D 0 3FA6POLU5LR260585 GSA FLEET ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 IL NATIONAL GUARD SELF INSURED 1 I—
t HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ey
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 DV
�2 0 0 4 Kia Motors Co�ptima 2020 00-NONE 11_"i Qj O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 I I., E FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 1 ENGAGED 1 15-OTHER 9, PO3 16-TO * X
®Y El DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 0
POINT OF s i1 �I COM VEH 0 ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5 r_
FIRST CONTACT 2 7� -5 •If Yes.See Sidebar
CARPENTERSVILLE IL 60110 0 1 0 ER16141 IL 2025 I0
IL D 0 5XXGW4L26LG396052 ALLSTATE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 802518155 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused E Y°®N 9 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 City of Elgin street address sign 11 ,27 ,2024 12 48 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 150 DEXTER CT ELGIN IL 60120 2 28 I 1 ❑PM ❑Construction >E
Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / El PM '
' u 1 ® 11 1 0 Utility
0 CITATIONS ISSUED ❑PENDING SLMT
o0 AM
N SECTION CITATION NO. ROAD CLEARANCE TIME
t 2 0 1 2 ARREST NAME hi27 12024 12 48 ®PM ElUnknown work zone type U1 30
2 2 3 ❑ 34 2 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
374 Rizzu o. Michael 201 404 Duffy , , ❑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
"„ -<
ao I I ; 1. Has a weight rating more than 10,000 pounds{example:truck or truck trailer
i- ;___-r----; ( combination)or
•, I INDICATE NORTH71
BY ARROW 2 Is used or desi ned to transport more than 15 C
i L °
_ (example:shuttle or charter bus):or passengers including the driver
r I I t Not TO Scale I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
L L____A____� ,,,,,,, `... - y } } . transportingemployeesInthecourseoftheirem ployment(example:employee 73
ww transporter-usually a van type vehicle or passenger car):or 03
-- } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. ,
{S' for direct compensation(example:large van used for specific purpose):or O
''
< L____a____. Q9' _ i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
T. �i placarding(example:placards will be displayed on the vehicle). ;p
/ ,n:'l1' p0./. __
II CARRIER NAME Z
ADDRESS 0
II
I I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
r ^a* ❑ Not in Comm./Govt. Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
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 M
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
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
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.
Arties/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 Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE