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HomeMy WebLinkAbout2024-00078178 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 1111 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403661600 u, 1 U21 2 4 1 U, 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 31,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00078178 VERY ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mBOWES RD Elgin ® ❑ RELATED ❑Y ®N 12 13 2024 ®AM ❑YES ® PRIVATE NO U1 mo /day/yr 11.09 ❑PM FLOW CONDITION M _ ®75 ®/MI N OE S W Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q Boelter. Ro er.W. 1 1 / yr 13-UNDER CARRIAGE 19.I 2 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 4 <<Tl M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76•TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL F. 6 I,.4 COM VEH 0 Ei 1 0 FIRST CONTACT 12 7_:—, _5 *II Yes.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 DM44133 IL 2025 REAR TELEPHONE IL A 7 JTMAB3FV8PD140397 GEICO ❑Y ®N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 4506908781 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 1 2 c p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv /1 9 5 6 Chevrolet H H R 2009 00-NONE ,�_"1 12..-_, DUE TO CRASH ❑ 0 2 x 0 yr 13-UNDER CARRIAGE to l 2 FIRE ❑ ® U2 C Po M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 3 X ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 1,,_4 COM VEH D ® Ut CO FIRST CONTACT 6 Y__{_O -_5 •If Yes.See Sidebar = ELGIN IL 60120 0 1 0 EF95959 IL 2025 REARn IL D 3GNCA13B79S569468 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 965343893 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND❑N 3 U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 02 / / / UI 2 :A D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12/13 /2024 11 09 ®❑PM 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 ✓ 2 28 03 12/13 /2024 11 10 ❑PM El Construction >F R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ®AM ❑Maintenance U2 a ® 11 1 ARREST NAME Boelter. Roger.W. 11-601 298001174W 12/13/2024 11 13 ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility AM 45 r 2 ElARREST NAME 12/13 /2024 11 30 M PM ❑Unknown work zone type U, n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 45 298-Lopez, Mirko 702 391-Jacobucci / / ❑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 truck trailer -< c ` -'- ' r INDICATE NORTH combination):or —I © I 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or C) ___; _wor to sow J ananaeaerrca - 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 } } } transporting employee In the course of their employent(example:employee X om..a transporter-usually a van type vehicle or passenger car):or CO I- }- --I-----; - } 1.} 4. Is used or designated to transport between 9 and 15 passen including the driver. C for direct compensation(example:large van used fors specific purose):or __ 1 - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D • placarding(example:placards will be displayed on the vehicle). ,Zmt —1 ��, CARRIER NAME Z • - '0 ADDRESS V) C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------4, - USDOT NO. ILCC NO. m XI Source of above z . 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'; 0 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 Gray Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ 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