Loading...
HomeMy WebLinkAbout2024-00078658 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets Mill I01101100 11111 0011111 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403661532 u, 1 U21 1 1 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 10 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2024I 2024-00078658 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 12 15 2024 ❑AM ❑YES IX]NO U1 -< W CHICAGO ST Elgin mo /day/yr 07:58 ®PM FLOW CONDITION m 00 ©no N OE S W South State St COUNTY PROPERTY 0 Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 ,A Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 FOR DAMAGED AREA(S) T TOWED U1 0 NAME(LAST,FIRST,M) Alfreha.Suleiman.A. mo Ford Fusion 201 2 00-NONE 13-UNDER CARRIAGE „_' QI 7T DUE TO CRASH ® ❑ I �:/ FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 al 0 DISTRACTED ® 0 U2 2 m M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®S NE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 5 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :i1 a �i, COM VEH 0 El 1 0 H F. HickoryHills IL 60457 0 1 0 FIRST CONTACT 1 7_; __5 *IIYes.SeeSidebar U1 ZEW60330 IL 2025 TELEPHONE IL D 0 3FAHPOHA6CR339142 United Security Insurance ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same ULS999294 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused El ® N 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑lily 0 i v 0 Dv /1 9 5 2 Honda CRV 2011 00-NONE O, 12.._, DUE TO CRASH p 2 73 O 13-UNDER CARRIAGE 0 I 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 11 7A s s i.�., 5 COM IfYes.VEH See Sidebar❑ ® U1 CO • ELGINZ IL 60124 0 1 0 3720523 IL 2025 REAR 0 N D - C IL D 0 JHLRE3H33BC002760 Safeco Insurance ®Y ❑N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same Z5225632 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 09 / :A / / UI 1 D / / 3 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 12/15 /2024 07 58 ®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 5 C) T 0 2 0 2 14 { / 0 PM ❑Construction X 1 R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Alfreha.Suleiman.A. 11-901-A 492000476 / / El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility 30 T 2 0 ARREST NAME AM T 1 / ❑❑PM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y SO 492-Gardrer. Mikaela 601 01 ,21 /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 -< ` ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X ,,,,,,,,,y.M. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I- } -A- -•i - } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L I I. 4. Is used or designated to transport between 9 and 15 passengers,including C}-----;----; - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or L L____a..... "'� t 5 Is any vehicle any e used to transport hazardous material(HAZMAT)that requires -D I = r .a vot,cnnwvs. placarding(example:placards will be displayed on the vehicle). XI ..-- o. D �--I ,:;r'-ICA _ _ _ _ CARRIER NAME Z ADDRESS O D w Not To Scale n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . xi 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 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 Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE