HomeMy WebLinkAbout2024-00078085 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 Ill 11 III1II DIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003661506
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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 15
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00078085 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mSHALES PKWY El09:00
® ❑ RELATED ®Y 0 N 12 12 2024 12,— ❑YES El NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W MAROON DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 4 !
yr 13-UNDER CARRIAGE ! FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ]$I U2 4 <<Tl
M 2 8 El ®SNE❑ 15-OTHER
UNK VEH. O ATCRASHIND O 99-UNKNOWN 916•TOPO `Detraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 it®COM VEH 0 E! 2 C)
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 2 7 •l -O •If Yes.See&debar IA O
Z M P22111 I L 2025 ' E
TELEPHONE
IL D 0 1 FM5K8AC3PGA19632 Alliant Insurance Service ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Elgin.City.o. 8109160P901 1
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r
RESPONDER
6 IV
x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑!My 0 KCy ❑Dv
Yr!2 0 0 1 Honda Civic 2009 00-NONE O QI-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
Fil
M 2 8
SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7� .6 •(ryes.See Sidebar
dc ELGINdc IL 60120 B 1 0 DZ74810 IL 2025 REAR 0 C
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IL D 0 2HGFA55559H703306 Bristol West ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Hernandez.Juan g01487750200 SAC E
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)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 12,12 /2024 09 00 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 10 99 12,12 ,2024 09 01 0 APMM ❑Construction
F
Z 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM ❑Maintenance U2
ARREST NAME 12,12,2024 09 06 ®PM
1 ® 11 1 4 0CITATIONS ISSUED ❑PENDING UtilitySLMT
o u2. SECTION CITATION NO. ROAD CLEARANCE TIME • El
0 AM
t 2 ❑ ARREST NAME 12 t 12 /2024 09 26 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ID AM Workers present? ❑Y 30
1545 VanEycke. Brier 302 334-Fries , , ❑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 ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
n
1. Has a weight rating more than 10,000 pounds{example:truck or truck trailer
--_--------; _<
�BIrIN?FMarrl u _ ) comWrtatlon):or _.
INDICATE NORTH p1
JBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
Not TOSotk; X
r 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
-A-.-.-
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L ':. ..}----+ - • } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
I I -- for direct compensation(example:large van used for specific purpose):or o
< <____a..... _ t < < < t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
61row F- --uon2 placarding(example:placards will be displayed on the vehicle). XI
00114 0 CARRIER NAME
J Z
ADDRESS D
I to
CITY/STATE/ZIPn
I - i. 4. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Public Works . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE