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HomeMy WebLinkAbout2024-00079642 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I01101100 000 lIII IIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a67a312. u, 1 u21 3 4 1 u1 5 U2 1 u, 1 u2 1 u, 1 u2 1 5 10 u1 6 u2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (8:1B Injury and/or Tow Due To Crash ❑AMENDED YR 202412024-00079642 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ®Y 0 N 12 20 2024 12,— ❑YES ®NO U1 -< S RANDALL RD Elgin mo /day/yr 07:00 ®PM FLOW CONDITION III 02O qC7!MI N E O W Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 0) 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 (i 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 3 n 0 3 / yr I ! FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 3 <<T1 SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 F 2 6 0 0 x ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction value 4 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i o II 6 ll COM VEH 0 El 1 Z Cicero IL 60604 0 1 0 FIRST CONTACT 5 7_;LQ_(. C) •IIYes.See Sidebar U1 0 EQ75093 IL 2025 FicAii TELEPHONE IL D 0 4S4BP61 C067306580 Progressive ❑Y Il N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 918013458 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 NOV 0 Dv /1 9 8 7 Hyundai PALISADE 2024 00-NONE O Qi-O DUE TO CRASH ❑ 2 o ©-UNDER CARRIAGE 10( I 2 FIRE ID ® U2 C c F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y MN DUNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI�1:,-4 COMVEH ❑ ® U1 CO FIRST CONTACT 12 7 _, -5 •If Yes,See Sidebar = ELGIN IL 60124 B 1 0 DV62913 IL 2024 0 IL D 0 KM8R3DGE1 RU800038 Allstate ®V 0 N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 811675064 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOBI (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL) 2 6 06 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y N 1 ® 11 1 12!20 /2024 07 01 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 11 1 24 99 12,20 /2024 07 01 PM ® , ❑Construction * R O ❑ CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Simon. Elidia. R. 11-708 154100050 12,20/2024 07 10 ®PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility t 2 El ARREST NAME 12/20 /2024 08 15 ®PM El Unknown work zone type U1 0 AM 50 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 50 1541-Wilkerson.Tondeo 801 246-Kite 1/ , 3/ /025 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 -< } }----'-----; I I I I L ` INDICATE ARROW combination):or —I p0 Iniosiwoa� 2 Is used or designed to transport more than 15 passengers including the driver 0 1 1 1 r r r (example:shuttle or charter bus):or X 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 w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y— - } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L II t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m IV — — placarding(example:placards will be displayed on the vehicle). ;p * I r e., 2). Not 7h Scale , lIn go CARRIER NAME Z ADDRESS 0 I ,: I 1 I �§ I CITY/STATE/ZIP T. n l MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI 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 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 Black Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE