HomeMy WebLinkAbout2024-00078238 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00366151/
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00078238 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED ❑Y ®N 12 10 2024 ❑AM ❑YES ®
PRIVATE NO U1
N STATE ST Elgin mo /day/yr 06:30 ®PM FLOW CONDITION M
•
0/MI O E S W LAWRENCE St COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR El SLOW 1 cn
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
18: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 6 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M)
Ruetsche.Justyna mo /1 9 8 7 Jeep(after 196 )Ind Cherokee 2014 00-NONE „ •
Q 0 OUETOCRASH ❑
13-UNDER CARRIAGE 10' : 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 6 rn
F 2 4 SY❑Y ®SNEM DUNK VEH. 0 AT CRASH IN 0 15-OTHER
99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL 6 I,.4 COM VEH ❑ 18l 1 O
m H West Dundee I L 601 1 8 0 1 0 FIRST CONTACT 1 7_'mR--5 *II Yes.See Sidebar U1
Z H920220 IL 2025 E
TELEPHONE
IL D 0 1C4RJFBG3EC215279 Farmer's Insurance ❑Y ICI N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Ruetsche.Charles 191918935 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 i v 0 DV
'1 9 6 0 Pontiac Grand Prix 2004 00-NONE ,._"j t2..-_, DUETO CRASH ❑ I1 2 x
o 13-UNDERCARRIAGE 10 1 2 FIRE 0 ® U2 C
ll
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 6 I,,_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 Y :j_O ._5 •)ryes.See Sidebar
n ELGIN IL 60120 0 1 0 DR25457 IL 2024 aR
C
IL D 0 2G2WS522441268113 American Alliance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same I LAA-0761495-02 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 6 05 / M 11 4 0 1
m
/ / #OCCS D
71
/ / UI 2 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 12/13 /2024 03 54 ®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 0 03 28
N 3 0 0 CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
—a, ARREST NAME / / El PM '
1 ® 11 1 1 UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
t 2 El ARREST NAME 12/10 /2024 06 32 ®PM El Unknown work zone type U1 300 AM
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1507 Ruiz.Alondra 601 334-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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or CO
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 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 ...._-..:__ 11 t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Red
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE