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HomeMy WebLinkAbout2024-00080773 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets Mill I01101100 II 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003681649 u, 1 U21 3 4 2 U, 1 U2 1 U, 1 U2 1 U, 1 U2 1 2 10 U1 1 U2 3 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2024I 2024-00080773 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 12 27 2024 DAM ❑YES IX]NO U1 -< E HIGHLAND AVE Elgin mo /day/yr 01.58 ®PM FLOW CONDITION Ill I0 ®!MI N E S © RIVERSIDE Dr COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 (8:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EOUES ❑uuv ❑!Cu ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 03 n .FROM Adenekan.Adebukola. K. Saturn Vue 2008 00-NONE 0 TOWED U1 Q 12 , DUE TO CRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I ! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O ' 2 DISTRACTED 0 0 U2 03 M F 2 4 ❑Y ®SNEM❑ 15-OTHER UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH 0 j$J 1 0 H F. HOFFMAN ESTATES IL 60192 B 1 0 FIRST CONTACT 11 7._; __s Yes.See Sidebar U1 Z ER16192 IL 2025 E TELEPHONE IN D 3GSCL33P58S725746 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Elgin Fire 99 9 Same 12RA000022408 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Provena St.Joseph ❑Y ElN 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEOAL ❑EWES ❑l uv 0 Ixv ❑Dv 1 9 4 2 Chevrolet Impala 2011 00-NONE 11_"I Qj O DUE TO CRASH ❑ 2 73 13-UNDER CARRIAGE I I! FIRE ❑ ® U2 7, F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i_i, COM VEH D ® U1 CO FIRST CONTACT 1 7�. -s •If Yes.See SidebarC n ELGIN IL 60123 B 1 FA11776 IL 2025 I 0 Z IL D 2G1WB5EK3B1325236 AllState ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 062457249 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,27 /2024 01 58 ®PM in a Work Zone? ®N DIRP co 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 � 2 ❑ 2 99 12,27 ,2024 02 25 ®PM ❑Construction Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 ARREST NAME 12/27/2024 02 00 ®PM o u ® 11 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 30 T AM 7 ❑PM ❑Unknown work zone type U1 2 El NAME , / ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 1506-Nunez. Maria 707 , / El 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 r ® - combination):or more thanpound (example:truck or truck/trailer 1. Hasaweight rating10,000 5 -I I INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - r r ,. (example:shuttle or charter bus):or Not To Scale f x 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O I- }____A____� E7NIGrl/�NU7AVE 1 i I } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w ' I. 4. Is used or designated to transport between 9 and 15 passengers,including cC/1 }--- ----+ - } } } g po passen rs,includi the driver, _ UNIT 1 for direct compensation(example:large van used for specific purpose):or L L____a____.I po,I,` at ,. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m �uNrc>— placarding(example:placards will be displayed on the vehicle). D i I ! CARRIER NAME UNIT z ADDRESS 0 V) I CITY/STATE/ZIP C) MOTOR CARR.ID ❑ Interstate ❑ Intrastate ( 0❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 --- --1 USDOT NO. ILCC NO. C m XI Source of above z . 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'; 0 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 Maroon Black 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