HomeMy WebLinkAbout2024-00081569 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 110 II
������ 1i1 1111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003681644
u, 1 U211 3 4 2 U1 7 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 11 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2024I 2024-00081569 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 12 31 2024 ®AM ❑YES ®NO U1
N RANDALL RD Elgin11:39
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W AUTO MALL DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) •R'ONT�OUETOCRASH TOWED U1 0Wittman.Sandra. M. 1 0 !
yr 13-UNDER CARRIAGE 10. • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 0 1 0
F. FIRST CONTACT 12 7_:— ___, _5 *Irves.See Sidebar U1
V Z Carpentersville IL 60110 C 1 0 DB15059 IL 2025 REAR
TELEPHONE
IL D 0 1 G8AJ55F96Z141515 Geico ❑v J N U2 ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire 99 9 Same 4453-15-99-74 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Sherman ❑Y ® N 2 0
N DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 uv 0 NCV 0 DV
'1 9$0 Toyota Camry 2018 00-NONE 'o,I t2 (,-2 FIRE DUE OCRASH 0 ® U2 2 73
C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑YNi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. & 1 S .t. 4 M ® Ut COF,,, STATE YEAR POINT OF
FIRST CONTACT 6 O7 ,=Q)OS •(ryes.COVEH See Sidebar❑ CELGINZ IL 60123 0 1 0 CU76663 IL 2025aR Si)0
M
IL D 0 4T1 B 11 H KOJ U 142369 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2486521-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMco
AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,31 l2024 11 39 ®❑PM AM in a Work Zone? ®N DIRP D
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 �
0 2 0 28 03 { ) ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Wittman.Sandra. M. 11-601-Ax S1540-000061 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
r 2 ElARREST NAME 12/31 12024 01 03 ®PM ElUnknown work zone type U1 50
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 50
1540-Allah. Muhammad sot , r 0 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••--, , I I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
wrrnsrxa 1.
Has combination):or ratingmore thanpound (example:truck or truckrtrarler -<10,000 s
` ' ' I r INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I - (example:shuttle or charter bus):or
} A i 3 r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
. - - -- I _ l I�t } } } transporting employee �In the course of their employment(example:employee
1 1 1 transporter-usually a van type vehicle or passenger car):or w
L L.___a__ ...I \ } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
NA +a s n r we for direct compensation(example:large van used for specific purpose):or o
L t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). m
"
CARRIER NAME Z
IJ.,.. 2#
A _ __ 1 ADDRESS 0
Iw
I I N CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
r Not To Scale I . ❑ o
I I Not in Comm./Govt. Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO.
I I XI
Source of above z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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
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
Red White
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: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE