HomeMy WebLinkAbout2024-00079618 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets IC HHH 11 III1II OUI 00110000111111I IV III DID
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00079618 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
RT20 RELATED ❑Y ®N 12 20 2024 04:43 DAM ❑YES ®No U1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT l MI N E S W SHANNON PKWY COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
TOWED U1 FOR DAMAGEDAREA(S) FRONT O
Saribekian.Jessica.A. 0 6 /
yr
13-UNDER CARRIAGE 1a i 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 I'T1
F 2 5 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 ,Distraction Value 6 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1a 4 COM VEH 0 Ea 1
Z Hampshire IL 60140 0 1 0 DB28532 IL FIRST CONTACT 12 7 ; _s *If Yes.See Sidebar U1 0
Ismi
TELEPHONE
IL 0 5N PD84LFOJ H267774 Progressive ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 983750441 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑Ruy 0 i v 0 Dv
/1 9 8 6 Honda Accord 2019 00-NONE ,i_"' t2 -_, DUETO CRASH ❑ (� 2
0 13-UNDER CARRIAGE to l E FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S iI S I,,_4 COM VEH D ® Ut CO
FIRST CONTACT 6 Y__{_O -_5 •If Yes,See Sidebar
= ELGIN IL 60124 0 1 0 BH41967 IL 2025 i
IL D 0 1 HGCV3F47KA004507 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 6134828661 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D0131 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 02 / M 2 4 0 1 0
m
/ / #OCCS D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,20 ,2024 04 43 ®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
0 2 0 03 03 , , ❑PM ❑Construction >F
4
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME Saribekian.Jessica.A. 11-601-Ax 154100049 t / El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
45
r 2 ARREST NAME AM
7 El r ❑❑PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑y 45
1541-Wilkerson.Tondeo 900 246-Kite 01 , 13,2025 01 30 ®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
i•____r____; I �N— _ I 1. Hasa or more than pound (example:truckortruck/trailer
c1. Hasa weight rating10 000 5
INDICATE NORTH Iron)
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not lb�� I _ (example:shuttle or charter bus):or
L L.___A.._.� •+i �1 - } } . transportinggemployeeslin the course r passengers
engerm and operated nt employee carrier 0
I ` + tra3.nsportr-uslly a van type vehicle or passenger car):(example:r w
L I---- ----; li fi - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, '
�`,; for direct compensation(example:large van used for specific purpose):or
L L____a..... t i. i. t 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
-o
XI
h, placarding(example:placards will be displayed on the vehicle).
CARRIER NAME
ADDRESS 0�� 0
II
i � - CITY/STATE/ZIP
I I I MOTOR CARR.ID 0 Interstate 0 Intrastate
❑ Not in Comm./Govt. Not in Comm./Other
;____Y_._ 4, USDOT NO. ILCC NO. m
XI
Source of above 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
co
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
Blue White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Mies/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE