HomeMy WebLinkAbout2024-00079373 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II �0011lUU ID I110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a671 71
u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) N B Injury and/or Tow Due To Crash
❑AMENDED YR 2024I 2024-00079373 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 12 19 202412,—AM ❑YES N NO U1 -<
N MCLEAN BLVD Elgin mo /day/yr 02:07 NPM FLOW CONDITION m
025 0/MI N E 0 W Weatherstone Ln COUNTY PROPERTY ❑Y N N DOORING El #OF MOTOR 0 SLOW 1 U)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 8
FOR DAMAGEDAREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) Jones. Edana. D. /1 9 5 9 Jeep(after 1968i�rokee 2017 00-NONE 012 _-, DUE TO CRASH ❑
13-UNDER CARRIAGE FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTHER TAL(ALL) EN
O ' 2 DISTRACTED 0 N U2 04 M213 F 2 4 ❑Y SYSNTEM❑UNK VEH. 0 AT CRASH 0 99-UUNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i:�—a �i 4 COM VEH 0 N 1 0
F. FIRST CONTACT 11 7_ __;__5 *llyes.See Sidebar U1
Z Carol Stream IL 60188 0 1 0 EV90141 IL 2025 REAR
TELEPHONE
IL D 0 1C4PJMDB3HW519602 Insure on spot ❑v IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same I LT5764888 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y N N 2 0
Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 iv ❑Dv
/1 9 9 8 Honda Civic 2004 00-NONE 0. Q!'-O, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n value 9 U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�:,-4 COM VEH 0 N CO
FIRST CONTACT 12 7 _,_.5 •If Yes.See SidebarC
F. 60110 0 1 0 DY99326 IL 2025 I 0 Si)
IL D 7 1 HGES16514L002676 Progressive ❑Y N N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Quiroga. Manuel. D. 967848796 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 09 / M 2 4 0 1 0
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71
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/ / 01 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2Z
N 1 ® 11 1 12/19 /2024 02 07 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 2 28 12/19 /2024 02 07 ®PM El Construction
>E
R 3 0 xi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Jones. Edana. D. 11-902 S1537-000060 12/19/2024 02 12 N PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 ElARREST NAME 12/19 /2024 03 00 0 PM ElUnknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1537-Mapp.Teddron 501 391-Jacobucci 01 /07/2025 09 00 ❑PM N 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 r -' -' r INDICATE NORTH combination):or .Z-1
I IL BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I N r r r (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I. } } transporting employees in the course of their employment(example:employee I °
- transporter-usually a van type vehicle or passenger car):or w
L L.___a___ I - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
4„ } } for direct compensation(example:large van used for speific purose):or 0
�' L i. i i ._ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
t I placarding(example:placards will be displayed on the vehicle). m
5 �
. CARRIER NAME Z
- ADDRESS 'n
D
w
Not To Scefe Ir CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
_ Source of above Z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
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 ❑ 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 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