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HomeMy WebLinkAbout2024-00081195 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 O0fl1lI II DID II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036 183.09- u, 1 U21 1 1 1 u, 2 U2 1 u, 1 1_12 1 u, 1 U2 1 5 10 u1 4 u2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash ❑AMENDED YR 202412024-00081195 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 12 29 2024 ❑AM ❑YES ®NO U1 -< E HIGHLAND AVE Elgin mo /day/yr 08:09 ®PM FLOW CONDITION M lxl 0 ®!MI NOS W Center St COUNTY PROPERTY ❑Y ® N DOORING ICI #OF MOTOR 0 SLOW 2 fA Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 / yr 13-UNDER CARRIAGE ©,I O,._2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 III F 2 4 SYTM❑Y ®S NE DUNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN - r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 Ea 2 O ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *llsees.See Sidebar U1 Z AD85582 IL 2015 REAR TELEPHONE IL D 0 1 N4AL3AP8FN368453 State Farm ❑v Il N U2 I' 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 0140300 SFP 13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER eM Refused 0 Y ® N 2 0 p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEOAL 0 EWES ❑New 0 NOV ❑Dv !1 9$0 Chevrolet Silverado 2015 00-NONE 'o l t2 ( 2 FIREo CRASH ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN O *Oistrac on Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- I�14 COM VEH ❑ ® U1 CO FIRST CONTACT 4 7�'—_,SOS •bYes,See Sidebar ELGIN IL 60123 0 1 0 3606764B IL 2025aR IL 0 1 GCVKREC1 FZ220209 Bristol West ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same G01488902000 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT( IDOBI (SEX) {SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 07 / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12,29 i2024 08 09 ®PM in a Work Zone? ®N DIRP co 1 F PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T o" 2 0 2 99 ( ( ❑PM• ElConstruction R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 o1El 11 1 ARREST NAME Lopez. Martha 11-906 W1529-000239 / / ID PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility 30 F 2 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1529-Audi red.Jonathan 301 334-Fries , / D PM Workers present? ®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. 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 truckrtrailer -< ` ` --I -' r INDICATE NORTH combination):or —I rre.,.ns. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } i A - } r r (example:shuttle or charter bus):or o . 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 4. Is used or designated to transport between 9 and 15 passengers,including y }--- ----; - } } } g po passen rs,includi the driver, • for direct compensation(example:large van used for specific purpose):or O i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m mai I- .. A — — — _ CARRIER NAME Z ux� O ADDRESS E?Highland?Ave. twit Not To Scale CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn XI Source of above z . 0 Yes 0 No ❑ Unknown A 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Black 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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE