HomeMy WebLinkAbout2024-00076924 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
I01101100 0 M 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003€51153
u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00076924 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 12 07 2024 ❑AM ❑YES ®NO U1
N STATE ST Elgin 12:35
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 '
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑KIN ❑!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Kovalevska. Hal na 1 0 /
yr
13-UNDER CARRIAGE 161 2 FIRE 0 lE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 0 m
F 2 SY4 ❑Y ONM DUNK VEH. 0 AT CRASH IN 0 15-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i COM VEH 0 Ea 1 0
~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 1 7 ;1 __5 *Ir Yes.See Sidebar Ut
Z EU11787 IL 2025 E
TELEPHONE
IL D 0 1 N4AL21 E99N443030 State Farm ❑v Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 2779768-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused 0 Y ElN 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
!1 9 yr 3 Ford Escape 2011 00-NONE O, ' 12..-_, DUE TO CRASH ❑ ! i 2 x
o 13-UNDER CARRIAGE 10� 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y Ig N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i 6 i.', COM VEH 0 ® U1 W
FIRST CONTACT 11 7 -5 •If Yes.See Sidebar C
E LG I N I L 60120 0 1 0 AS23656 I L 2025 REAR 0 fp
IL D 0 1 FMCUODG8BKC09319 American Alliance ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ILAA-0993921-00 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (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
co
N 1 El 11 4 12,07 l2024 12 35 ®pM in a Work Zone? Igi N DIRP D
1 IT PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
0
2 ❑ 2 18 , / ❑PM• ❑Construction *
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Kovalevska. Halyna 11-901-A 499000732 r ! 0 PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
8 N ❑AM
t 2 0 ARREST NAME Duran.Jose.G. 6-101 499000731 r r 0 PM 0 Unknown work zone type U1
n 45
-r OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
499-Dirck.Cameron 601 275-Engelke r r ❑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
A ADDITIONAL UNITS FORMS.
. 0
r ----r••--, , I N . A CMV is defined as any motor vehicle used to transport passengers or property and: Z
_ Not To Scale 1 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }--__r-_--; I } INDICATE NORTH combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I - } (example:shuttle or charter bus):or 0
< <---- -•-•; I transporting mployeened to sl5 or fewer in the course passengers thir emplod yment example:employee
transporter 1 cAka o?3t I. } } }
` 7 6ransportet-usually a van type vehicle or passenger car):or co
GIP
i_ L-----}----; mo - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
1� for direct compensation(example:large van used for specific purpose):or
N .c:'..
L L____a____. 1,�, i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
N D P.. placarding(example:placards will be displayed on the vehicle). XI
- —I
CARRIER NAME Z
ADDRESS 0
w
0
i CITY/STATE/ZIP g
- MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. Did Carrier Safety es Regulations 0 N)oviol0 violation
own to the crash? 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE