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HomeMy WebLinkAbout2024-00075798 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 01011 I 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40364552� u, 1 U2 1 1 1 U, 8 U2 U, 1 U2 U, 1 U2 1 1 9 U1 1 U221 *P 0119* 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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00075798 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 12 02 2024 ®AM ❑YES ®NO U1 —< TODD FARM DR Elgin mo /day/yr 10:42 ❑PM FLOW CONDITION M_ 010(D!MI N E O W Todd Farm Ct COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER t] PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 4 / yr 13-UNDER CARRIAGE ©i !._2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 2 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a ii COM VEH 0 Ea 1 C) f. FIRST CONTACT 11 7__ --_;__5 *II Yes.See Sidebar U1 0 Z ELGIN IL 60123 0 1 0 EV12447 IL 2025 REAR TELEPHONE IL D 0 3FADP4BJ4CM175868 American Alliance Cas.Co ❑Y ®N U2 1- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Ojeda. Maria.A. ILAA099782100 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 As ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 Kcv 0 DV yr Nissan Versa 2014 00-NONE O z -_, DUE TO CRASH ❑ ® 1 7./ o 13-UNDERCARRIAGE 9I Vile 2 FIRE ❑ ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 X a ❑ NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value POINT OF 8 it 4 ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��'`_ COM VEH ❑ ® CO FIRST CONTACT 11 7 _5 •If Yes.See Sidebar H EE53530 IL 2025 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 3N1CN7AP7EL848120 State Farm ❑Y 123 N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Buzo.Saldana.J. 1030382SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 12,02 ,2024 10 43 ®❑AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 20 99 1 / ❑PM 0 Construction * R 3 0 0 CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 o ® 11 1 ARREST NAME Zujko. David. D. 11-709-A 495000426 / r El PM SLMT o N ElCITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 30 r 2 ARREST NAME AM 7 1 7 ❑❑PM 0 Unknown work zone type U1 El 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 495-Sjodir.Jacob 501 275-Engelke 01 ,21 ,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 f ( r I ® f 1. Hassa orratingmore than pound (example:truck or truckrtrarler 1. a weight 10 000 5 , INDICATE NORTH Ilon) BY ARROW c2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or C)3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O ji } r } transporters- mplluy a s in the course their employment(example:employee X po y type passenger car):or wL L.__-a-_-_1 •4. Isusedordesinatedtotrans rtbetween9and15 ssen rs,includingthedriver. 'CD1� } : } for direct compensation(example:large van used for specific purpose):or 0 L L--_-a-___-I \ t i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p_ F '\,� CARRIER NAME Z / O Unit91 �� 474ry'o - ADDRESS T.l614, 1, '�s C) CITY/STATE/ZIP 0 Unit?2 MOTOR CARR.ID 0 Interstate ElIntrastate ' Not To Scale I \ ❑ Not in Comm./Govt. 0 Not in Comm./Other ;_...Y. ._.; USDOT NO. ILCC NO. m 73 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 co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Red 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE