HomeMy WebLinkAbout2024-00078842 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a672830*
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 0 ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00078842 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 mDOUGLAS AVE Elgin04:50
® ❑ RELATED ❑Y ®N 12 16 2024 12,.. ❑YES ®NO U1 -<
_ -COUNTY PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W E GH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FROrar TOWED U1 O
Mason.Charles. L. Hyundai Trailer 2025 0-NONE „ , DUE TO CRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rr1
M I 2 4 ❑Y ❑SNEM® 15-OTHER
UNK VEH. 9 AT CRASH IN ENGAGED9 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6- l 6 1, COM VEH ® 0 1 C)
Z Chicago I L 60628 0 1 0 991627ST I L 2024 FIRST CONTACT 7 Qi _ __s ves.See Sidebar Ut
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7 TELEPHONE
IL A 7 3H3V532K4SJ151032 Carolina Casualty Insuran ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
H M D Leasing LLC KCA2600002-4 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER
98 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EWES ❑row 0 KV ❑Dv
!1 9 9 2 Subaru Outback 2020 00-NONE O, t2..-_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10 I E FIRE 0 El U2 C
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3
❑Y El ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 11:, 4 COM VEH 0 ® U1 W
FIRST CONTACT 11 7� , 5 •If Yes.See Sidebar
~ ELGIN IL 60123 0 1 0 EK13060 IL 2025aR g
M
IL D 4S4BTANC1 L3101278 State Farm ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
Same 1988838-sfp-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (D081 (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
2 3 12 /
2 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 12,16 /2024 05 50 0 pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 18 18
N 3 0 0 CITATIONS ISSUED ID PENDING 1 1 _ ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a ARREST NAME / / ID PM '
o, N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
25
r 2 ARREST NAME AM
7 1 / ❑❑PM 0 Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 560 Martirez.Samantha 101 334-Fries , / ❑❑PnMn Workerspresent7 ®N U2 25
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- -, , ; ; , ; ( combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' I , } (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 co
I- <.__-a-_-_- , l• I- I- <--_-I--___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L-. ..i.. -_.I L L L ...._-�_ ; t 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
CARRIER NAME H M D Leasing LLC z
ADDRESS 10031 VIRGINIAAVE 0
T.
, CITY/STATE/ZIP Chicago Ridge 1 IL 160415 g
MOTOR CARR.ID El Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
-----Y----4 I- I- Y- ; ; ; 976560 130349 USDOT NO. ILCC NO. m
x
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ®No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®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 0 z
TRAILER 2 0 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. w
White Brown
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE