HomeMy WebLinkAbout2024-00076300 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03€54690
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT 0 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 El OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202412024-00076300 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 12 04 2024 ®AM ❑YES ®NO U1 —<
N MCLEAN BLVD Elgin11:25
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRO / TOWED U1 Q
Koulis.Geor e.J. 0 8 /
yr
13-UNDER CARRIAGE 101 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 14 U2 4 rn
M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI S �i 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 B 1 0 FIRST CONTACT 1 7 ;1 __5 *u Yes,See Sidebar U1
ZCA41794 IL 2025 E
TELEPHONE
IL D 0 State Farm Ely igi N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 0915939-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y ® N 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 l uv 0 e v 0 DV
!2 0 yyr 5 General Motorfiil6a'rp 2000' 00-NONE 10' 12 c,�2 FIRE DUE O CRASH D ® U2 2 C
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F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9:1,6•TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN •0istraction Value 0
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
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ELGIN IL 60123 0 1 0 2945077B IL 2025
FIRST CONTACT 7 (ryes.See Sidebar
IL D 0 1 G KDT13W7Y2244943 Kemper ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Rojano-Gomez.Agustin 12A0000878413 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,04 /2024 11 25 ®❑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
Eri 2 17 99 12,04 ,2024 12 00 PM
® ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
ARREST NAME 12,04/2024 12 03 ®PM
o N ® 11 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT
45
T 2 ARREST NAME AM
7 1 7 ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1522 Velazquez. Noeli 502 275-Engelke r iElPM ®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 -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
% - (example:shuttle or charter bus):or
I I1. 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
I- }----A-----I
es pa g pe
} } } transporting employees in the course of their employment(example:employee � �
I ei..v.vkl transporter-usually a van type vehicle or passenger car):or w
L }-----}----; ——ijr _____ - I. } I. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)"-- -- for direct compensation(example:large van used for specific purpose):or 0
L L____a____. ---- _ i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
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2 Z
I I CARRIER NAME O
)• I I _ ADDRESS
I I rn
Hae girit_i I I CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I . 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- -"'- - USDOT NO. ILCC NO. rn
XI
_ Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II 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
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE