HomeMy WebLinkAbout2024-00080118 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111 III 11 III1II OUI 001100001flJDI IV
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00080118 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
LONGCOM MON PKWY Elgin 09:21
® ❑ RELATED ®Y 0 N 12 23 2024 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION I11
FT!MI N E S W BECKMAN TRL COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR 0 SLOW 2 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 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 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Hasan.Anwar. H. 0 9 /
yr 13-UNDER CARRIAGE 101 !. 2 FIRE 0 0
•STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 M
M 9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP
O3 * _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;ii 6 if.4 COM VEH ❑ 0 1 0
~ ELGIN IL 60124 0 9 0 FIRST CONTACT 3 7_;L _-5 *II yes.See Sidebar U1
Z ED11278 IL 2025 REAR
TELEPHONE
IL D 1 FMCU03116KA39078 None ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same None 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER
3 eu
��, g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 ivy 0 Ncv 0 Dv
1 9 5 3 General MotorSiQoEp 2021 00-NONE 111' t2 (,-2 FIREo CRASH ❑❑ U2 2 C o Yr 13-UNDER CARRIAGE
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M 2 4 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN •Oistraglon Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'i��j 6 i;,_ COM VEH 0 0 U1 CO
FIRST CONTACT 7 ®J -5 *IT Yes.See Sidebar
Marquette MI 49855 0 1 0 EAQ4634 MI 2025 REAR0 N
MI B 3GTU9DETXMG187489 Farm Bureau ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same PA10851436 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND Y N 3 u1 =
(UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 1 2 /
U1 1 D
/ / 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 4 12,23 ,2024 09 21 ®❑pM AM in a Work Zone? ®N DIRP D
co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 20 1 1 ❑PM ❑Construction
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Hasan,Anwar, H. 11-601 298001175 1 / El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO.
o ROAD CLEARANCE TIME ❑ El Utility
N AM30
T 2 ElARREST NAME Hasan.Anwar. H. 11 306 298001178 1 1 ❑pM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
298-Lopez, Mirko 801 404-Duffy 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
} (example:shuttle or charter bus):or
' 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee
[0--
! transporter-usually a van type vehicle or passenger car):or w
-- -- ® - } } } C
•4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or o
r,e,,,,,,, - } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
L L A
placarding(example:placards will be displayed on the vehicle). m
Not To Scale 3 i I D
L
Ie CARRIER NAME go Z
!..; ADDRESS 'n
T.
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I r I ❑ Not in Comm./Gout. 0 Not in Comm./Other
;------ --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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
Silver White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE