HomeMy WebLinkAbout2024-00077614 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 1111 III 11 IIIIII OUI
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-00077614 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
NESLER RD Elgin05:53
® ❑ RELATED ®Y ❑N 12 10 2024 ❑AM ❑YES El NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W RT20 COUNTY PROPERTY ❑Y ® N DOORING 10y #OF MOTOR 0 SLOW 15 u)
❑ 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
g DRIVER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 NW ❑lacv 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
T
0 5 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<rl
M I 2 5 ❑Y ®SNEM D15-OTHER
UNK VEH. O AT CRASHD O 99-UNKNOWN 9 7I6.TOP 3 ,Distraction Value ALGN 2
F F
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST NT OONTACT 12 O7 _'L Q;_05 ClOves.See Sidebar VEH ❑ !� U1 1 0
Z ELGIN IL 60124 0 1 0 SUGOPAL MD 2025 REAR
TELEPHONE
MD D 0 5NPEC4AC9CH352420 StateFarm ❑Y IlN U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1029068SFP13 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 ❑ FED ❑PEDAL 0 EWES ❑NMV 0 K v ❑DV
!1 9 6 7 Hyundai Tucson 2024 00-NONE id t2 c,�2 DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac) n Value 0
POINT OF S iITN4 COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
FIRST CONTACT 6 O7 ,�_ OS •IfYes See Sidebar C
Pingree Grove IL 60140 0 1 0 EN95210 IL 2025 I AR0 Si)
IL D 0 KM8JCCD11RU221219 Horace Mann ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 65000090120101 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (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
u 1 ® 11 1 12,10 /2024 05 53 ®AM in a Work Zone? Igi N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
Si 2 ❑ 11 1 08 99 12,10 /2024 06 02 PM
® • ❑Construction �F
R 3 ❑ 8 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ❑AM D Maintenance U2
-a, ARREST NAME POLAMREDDY. PRASANT 11-501-A-2 752483 12/10/2024 06 19 Igi PM SLAT
1 ® • ❑Utility 11 1 CITATIONS ISSUED ❑PENDINGING
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 ❑ ARREST NAME POLAMREDDY. PRASANT 11-501—A-1 752484 12/10 /2024 06 39 ® 45
PM El Unknown work zone type u1
2 2 3 El Elm ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1528-Rivera. Kevin 801 01 ,28,2025 09 00 ❑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 -<
INDICATE NORTH combination):or —I
p1
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
rinazio (example:shuttle or charter bus):or C)
iri rnr7b 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
I- L.__-A-.-.� I. R^�.ra, _ y } } } transportingemployees in thecoursee of their employment
pbyment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L -----------; ` - •} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or O
L i t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
_ CARRIER NAME Z
ADDRESS
w
C)
CITY/STATE/ZIP g
Not 7b Scale I - MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------4. - USDOT NO. ILCC NO. m
XI
Source of above z
PERMIT NO. WIDELOADo ❑Yes 0 No =
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . 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