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HomeMy WebLinkAbout2024-00081129 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II HID II III 0 100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xc03675963 u, 1 U21 1 1 2 U, 2 U2 2 U, 1 1_12 1 U, 1 U2 1 1 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 202412024-00081129 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ❑Y ®N 12 29 2024 ❑AM ❑YES ®NO U1 -< NESLER RD Elgin 12:20 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m E320 /MI N E S IA, Route 20 HwyCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ® 0Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 1 2 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 DI E NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 m M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 j$J 1 0 ~ Hoffman Estates IL 60169 0 1 0 FIRST CONTACT 2 7_: __5 *lIves.SeeSidebar U1 ZEJ43189 IL 2025 REAR TELEPHONE IL D 1 HGCP3F8XBA005342 Geico Ins Co ❑v ®N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 4582053411 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y 0 N 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEOAL 0 EWES 0 lily 0 NOV 0 DV CIRCLE NUMBER(S) U1 /2 O 0 2 Fiat 500L 2016 00-NONE 0. Q!'-O DUE TO CRASH rg ❑ 2 x 0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 POINT OF 8 i1�i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •(ryes,See Sidebar — Elgin IL 60124 B 1 0 DY85931 IL 2025 I 0 C IL D ZFBCFYCT8G P435241 State Farm Ins Co ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Blanco.Jose 1860418SFP13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB( (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) 1 3 11 / ' D / / 2 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME co DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12/29 /2024 12 20 ®PM AM in a Work Zone? ®N DIRP D 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 v 2 2 99 12/29 /2024 12 40 ®PM El Construction >E R 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 au ® 11 1 ARREST NAME Wegner. Devon. P. 11-801-B 481000229 12,29/2024 12 45 ®PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility t 2 El ARREST NAME 12/29 /2024 12 50 0 PM El Unknown work zone type U1 0 AM 5O 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50 481-Rodriguez. Hannah 801 312-Rigano 01 /21 /2025 01 30 ®PM I 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 -< i- ;.--__r-_--; A r INDICATE NORTH combination):or -I p1 tV BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I - } (example:shuttle or charter bus):or Not To Scale X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L •:. __}----; - I. } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C I I Unite I for direct compensation(example:large van used fors specific purose):or 0 __ ll _ < < _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m , ....) is Nealer4Rd placarding(example:placards will be displayed on the vehicle). D 3190?US _'� -I Rarta7S0 CARRIER NAME Z ( ;_;j _ ADDRESS O I5 CITY/STATE/ZIP g i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - 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 to 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 Gray Green u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE