HomeMy WebLinkAbout2024-00078643 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202412024-00078643 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N RANDALL RD Elgin05:20
® ❑ RELATED ®Y 0 N 12 15 2024 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
_
FT N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ 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
QT3 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 00 C)
0 3 !
Toyota RAV4 201 9 00-NONE Q. O 17.1 DUE TO CRASH ® ❑
13-UNDER CARRIAGE } �:/ FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 !� U2 OO r<n
F 2 4 El ®NNE❑ IN ENGAGED
UNK VEH. O AT CRASH 99-OTHERWN 916•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH 0 j$J 1 0
F.
ELGIN N I L 60124 0 1 0 FIRST CONTACT 12 7 ; __5 *If Yes.See&debar U1
Z EL32572 IL 2025 E
TELEPHONE
IL D JTMP1 RFV2KD041387 ALL STATE ❑Y ®N U2 19 . Rr'I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same 962646861 2 m
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 r uv 0 NCv 0 Dv
!1 9 8 3 Honda Accord 2007 00-NONE „ " OI'O, DUE TO CRASH rg ❑ 2 73
o 13-UNDER CARRIAGE I, FIRE 0 ® U2
Ti
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PONT OF
FIRST CONTACT 12 7A 6 L`_5 CIOMesvSeeSidebar❑ ® U1 CO
H ELGINZ IL 60123 B 1 0 DL63757 IL 2023 I 0 fp
M
IL D 1 HGCM56797A010924 GEICO ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 6186002561 BAG 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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 12,15 l2024 05 20 0 pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 0 2 99 + ! ❑PM• 0 Construction X
N 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
o1 ® 11 4 ARREST NAME Nuam.Grace.V. 11-902 1506-315 / ! ❑PM SLMT
o N
•
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
45
t 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 56
1506-Nunez. Maria 502 01 , 14/2025 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 truck trailer -<
` ` -' -' 0 I. INDICATE NORTH combination):or
531
11 I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I Not To scale } ,.,. (example:shuttle or charter bus):or
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3. Is designed to carry 15 or fewer passengers and operated by a contract career I O
I. } } transporting employees in the course of their employment(example:employee
r transporter-usually a van type vehicle or passenger car):or w
4.__ alo7ttkleetxno ( 1 1.. } 1. •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
D
L L____a____� — _ _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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placarding(example:placards will be displayed on the vehicle). ;p
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1 t
s I? i CARRIER NAME Z
i.
ADDRESS 0
ICCITY/STATE/ZIPOC)
_ i. MOTOR CARR.ID 0 Interstate El Intrastate
` 0❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
---"-4. USDOT NO. ILCC NO. C
m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
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
Silver Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE