HomeMy WebLinkAbout2024-00081588 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El 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)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00081588 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :l
® ❑ RELATED PRIVATE ❑Y ®N 12 31 2024 ❑AM YES ®NO U1
NATIONAL ST Elgin mo /day/yr 0125 ®PM FLOW CONDITION III
®2040/MI NOS W South Grove St COUNTY PROPERTY 0 Y ® N DOORING Ely #OF MOTOR NISLOW 15 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
Lorenzo. Harry0 2 /
yr Hyundai Tiburon 13-UNDER CARRIAGE 16 I 2 : 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i1 , I,. COM VEH 0 Ea 0
~ ELGIN IL 60120 0 1 FIRST CONTACT 12 7 ;{ _5 *IrYes.See Sidebar U1
Z EQ47508 IL 2025 REAR
TELEPHONE
IL D KMHHM65D73U018137 State Farm ❑Y IglN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same 2893983-SFP-13 3 m
17
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El El 2 eu
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDA. 0 EWES 0 iiuv 0 NCv 0 DV
/1 9 yf 4 Chevrolet Equinox 2024 00-NONE 'VI i 12..-_, DUE TO CRASH ❑ 2 x
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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F 2 4SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 0 X
0 Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 5 7 H1,"®i-__5 CIOf Ms geeSH idebar❑ ® U1 CO
C
ELGIN IL 60120 0 1 EE83473 IL 2025 0
4M
IL D 3GNAXWEG3RS207892 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 1736774-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
KNIT) (SEAT) (DOB) (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 12/31 /2024 01 25 ®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
o"
2 28 99 ( / 0 PM• El Construction
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R 3 0 xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
-a ARREST NAME Lorenzo. Harry 11-601 414-990W / / ❑❑PM ❑Maintenance U2
o N ® 11 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
,
r 2 ❑ ARREST NAME AM
7 ( / PM 0 Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
414-Lara. Saul tot / / ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <--_- -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_, , < <--_-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 L___-a____.: L L L ...._-.�____� l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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. Z
Red Silver
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE