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HomeMy WebLinkAbout2024-00077273 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets — 01111101111 01101100 0111110101 111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a€5472 u, 1 U21 1 1 1 U, 9 U2 1 U, 1 U2 1 U, 1 U2 1 1 16 U123 U211 *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 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2O24I 2024-00077273 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m ® ❑ RELATED ❑Y ®N 12 09 2024 ®AM ❑YES El NO U1 -< SCH I LLER ST Elgin PRIVATE mo /day/yr 10:04 ❑PM FLOW CONDITION m �O C.'J!MI N E S © North STATE St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 fA Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ® STOPPED U2 -I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 3 / yr 13-UNDER CARRIAGE IR 10 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O AT CRASHO 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2 T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $..it I, 4 COM VEH 0 Ea 2 C) H Z Chicago I L 60647 0 1 0 3497077 IN 2025 FIRST CONTACT 7 O7 _:REAR 6 __5 *Ir ves.See Sidebar U10 c TELEPHONE IL A 7 3HSDZAPRORN456609 PROTECTIVE INSURANCE CO. ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m R&LTRANSFER INC B-11321 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER L RESPONDER 0 N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑NUV ❑Ncv ❑Dv /1 9 5 6 Volvo S60 2002 00-NONE „ 12.._1 DUE TO CRASH 0 !1 2 73 o Yr 13-UNDER CARRIAGE FIRE ID El U2 M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X 0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0 POINT OF s I 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6 l:',_ C FIRST CONTACT 11 7 _, _6 •(ryes.See Sidebar BARTLETT IL 60103 0 1 0 FREDS78 IL 2025 RE N Z IL D 0 YV1 RS61 R322146850 STATE FARM ❑Y 123 N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = KUEHN. MICHAEL. R. 2571556SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 < RESPONDER U1 = !UNIT} (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##OCCS y / ,, U1 1 D 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 12,09 l2024 10 04 ®❑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 0 2 30 99 / ! ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 -a, ARREST NAME DIAZ-LOPEZ.WILFREDO 11-1402-A W244-1794 / ! El PM SLMT o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 30 t 2 0 ARREST NAME AM 7 ! r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 244-Blomberg. Michael 501 275-Engelke / ❑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. • A CMV is defined as for vehicle used to transportand: r ----,5-••--, ; any motor passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } } } ,- -, , 4 ; , 1, ( combination):or —I INDICATE NORTH x1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' 1 , } (example:shuttle or charter bus):or X 3. Is L L----A--- 1 '----- .- J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , < '---_-a-_--- , J. , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____; L L L i.___4____; ; ; ; I. i i • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt —D7 CARRIER NAME Z i. ADDRESS 0 T. , n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 .----Y----4 - - - ,--- -Y- 4 ; , ; : USDOT NO. ILCC NO. m Xl Source of above z . MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C z Form Number 0 m P3 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 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Green Tan 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 TDUE TOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.DUE T ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE