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HomeMy WebLinkAbout2024-00078975 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 01111110100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY xo03654146 u, 1 U21 3 4 1 U, 7 U2 1 U, 1 u2 1 U, 1 u2 1 1 11 U1 1 u2 1 *P 0 11 9* 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 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00078975 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 12 17 202412,--AM ❑YES El NO U1 -< S RANDALL RD Elgin mo /day/yr 12:52 ®PM FLOW CONDITION Ill I 40 ® 0 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 fA !MI E S W South St WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0 Ig 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) FRONT TOWED U1 Q Gu Gwendol n 0 5 / yr 13-UNDER CARRIAGE © IE 10,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn F 2 4 ❑Y ❑SYTHER SE El UNK VEH. 9 AT CRASH M IN ENGAGED9 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH 0 0 1 0 f. FIRST CONTACT 11 7_:—__;__5 *Ilves.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 MU4709 IL 2025 REAR TELEPHONE IL D 0 JN8AT2MV2LW101027 TRAVELERS ❑Y JN U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 6140219722031 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 D Refused ❑Y ❑ N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 RED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv Yr Mazda Mazdaspeed 6 2018 00-NONE 'o,I t2 c 2 FIRE DUE OCRASH 0 ® U2 2 73 C o mo 13-UNDER CARRIAGE c M 2 4 SYSTEM IN g ENGAGED g 15-OTHER 9.1,6•TOP 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value g g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 I!I,-4 COM VEH ❑ ® U1 CO FIRST CONTACT 5 7 _,„OS •If Yes.See Sidebar ELGIN IL 60123 0 1 0 DD86036 IL 2024 I 0 Sn IL D 0 J M 1 G L1 WY7J 1305192 PROGRESSIVE ❑Y ISI N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 AH U MADA.ZULEYMA.J. 936785107 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 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 12/17 /2024 12 52 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � Oi 2 0 28 03 N 1 3 0 0 CITATIONS ISSUED 0 PENDING / / ❑PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1 -a, ARREST NAME / / El PM ' S' N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT t 2 ❑ 45 AM T ❑PM 0 Unknown work zone type U1 ARREST NAME / / ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 326-Hornsby. Marc 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. 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 -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L--------- 1 i. ,--.-- -___� 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 1:0 < <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi nated to trans rt between 9 and 15 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 ,.___-.�_ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt D—I CARRIER NAME Z i. ADDRESS 0 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 . 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Blue,Dark Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO: _Unknown SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® Unknown VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE