HomeMy WebLinkAbout2024-00079405 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
I01101100 DVII I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a666272
u, 1 U21 1 1 3 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 5 12 u1 2 u2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00079405 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 12 19 2024 12,—AM ❑YES IX]NO U1 -<
RT20 WB Elgin mo /day/yr 04:37 ®PM FLOW CONDITION m
®5 FT/® N E S ® South State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR SLOW 2 fA
Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DOSTOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nuv ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
0 6 / yr Kia Motors Cott5 2025 00-NONE
, 12 DUE TO CRASH ❑ VI E
13-UNDER CARRIAGE 10 1 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
F 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a �i 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 11 7_:—_;__5 *IIYes.See Sidebar U1
Z Glendale Heights IL 60139 0 1 0 EU47941 IL 2025 REAR
TELEPHONE
IL D 0 3KPFU4DE9SE009852 Progressive ❑Y Il N U2 10 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Leomerys. Urbina 988753202 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 1 CXI
))
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 Ncv ❑Dv
yr 12
0 13-UNDER CARRIAGE 10( 2 FIRE ID El U2 C
M 2 4SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X
0 Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0
POINT OF 8 i1�.-4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 1 Y _, _5 •• •If Yes.See Sidebar
H Maple Park IL 60151 0 1 0 34233232 IL 2024 RFJ 0 N
IL D 0 1 C6RR7LMXGS211555 Country Financial ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same P12A3140539 BAc E
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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 12,19 /2024 04 37 ®AM 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)
T
0
2 ❑ 2 28 1 1 0 PM• El Construction *
Z3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
o1 ® 11 1 ARREST NAME Aranguren. Leonesky.A. 11-708 W494000361 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
55
r 2 0 ARRESTNAME AM
T / / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 494-Kirsh. Katherine 701 334-Fries / / ❑❑PM Workers present? ®N U2 55
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 truckrtrailer -<
} 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
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 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 CO
< <.__-a-_-_, , < <--_-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 ...._-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
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
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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
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. Z
Blue Silver
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE