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HomeMy WebLinkAbout2024-00076806 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 111111D �� h� 1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003€51169* u, 1 U21 3 4 1 U1 7 U2 1 U, 1 1_12 1 U1 1 U2 1 5 11 u1 1 u2 1 *P 0 11 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q 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 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00076806 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn SHALES PKWY Elgin06:20 ® ❑ RELATED ®Y 0 N 12 06 2024 12— ❑YES IX]NO U1 -< g PRIVATE mo !day/yr ®PM FLOW CONDITION m _ FT!MI N E S W RT20 COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 15 u) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 9 n FOR DAMAGEDAREA(S) FRONT TOWED EN U1 0Patel. Bhumika A ury 0 7 / yr 13-UNDER CARRIAGE ©,I :•: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 9 M F 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,;il S 4 COM VEH 0 Ea 1 0 H F. BARTLETT I L 60103 0 1 0 FIRST CONTACT 12 7 . _5 *II Yes.See Sidebar U1 ZAV50467 IL 2025 Ismi TELEPHONE IL D 0 5N PE34AF7J H686548 State farm ❑Y IlN U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 0806593-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv 0 NCv ❑DV CIRCLE NUMBER(S) U1 !1 9 9 7 M ^ NAME(LAST,FIRST,M) Sobremonte. Erica Subaru Outback 2024 00-NONE id 12 2 DUE O CRASH 0 ® U2 C 2 o Yr 13-UNDER CARRIAGE c,� D c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value U1 0 POINT OF 8 i 4 COM VEH ❑ ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QOS •It Yes.See Sidebar C Z Gilberts IL 60136 0 1 0 EF28524 IL 2025 I AR0 Si) IL D 0 J F2G UADC7R8300583 Allstate ❑Y ®N RDEF ZI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 811 355 505 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 1 12,06 l2024 06 20 ®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 C) v 2 28 99 12,06 /2024 06 20 ®PM El Construction * Z 3 0 ]$g CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 oEl 11 1 ARREST NAME Patel. Bhumika Apury 11-601-Ax 1527-00025 ! ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM t 2 0 ARREST NAME 12/06 /2024 07 00 ®PM 0 Unknown work zone type U1 5O 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? D Y 50 1527-Juarez.Jorge 401 334-Fries 01 ,28/2025 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 -< i- }---.r----; INDICATE NORTH combination):or p3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C fl _ (example:shuttle or charter bus):or `� 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O - L____A____� m ® - y } } . transportingemployeesinthecourseoftheirem tpbyment(example:employee � i. i. ..I.,.. ...I. - • } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15enger r including the driver. C m, `.� W/B?Route?20 for direct compensation(example:large van used for specific purose):or L ———- t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D ————- placarding(example:placards will be displayed on the vehicle). ,Zmt o tis - —D{ CARRIER NAME ADDRESS 0 ( 1I I CITY/STATE/ZIP 0 I I � i.rramr yJ I I _ 1 MOTOR CARR.ID 0 Interstate 0 Intrastate I I 0 0 Not in Comm./Govt. 0 Not in Comm./Other 0 -I. ------1 - USDOT NO. ILCC NO. C m 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 co LOCAL USE ONLY TRAILER VIN 2 m v 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 Silver White 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