Loading...
HomeMy WebLinkAbout2024-00081654 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII OUI 0011000011111001111110II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003681565 u, 1 U21 3 4 1 U1 8 U2 1 U, 1 u2 1 U, 1 u2 99 5 10 u1 3 U2 3 .P0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-S1,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00081654 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 ® 0 RELATED ®Y ❑N 12 31 2024 ❑AM ❑YES ®NO U1 W CHICAGO ST Elgin06:35 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD DO U2 —I Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 wcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 9 / yr 13-UNDER CARRIAGE 1a l !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171 M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®S NE❑UNK VEH. O AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B ii,4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut ZCY55683 IL 2025 REAR TELEPHONE IL D 0 KL4AMCSL2SB061272 Farmers ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 192202479 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ® N 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 KCV 0 DV '1 9 8 1 Volkswagen Beetle 2013 Do-NONE O,' t2 "_t DUE TO CRASH 0 ® 99 xi 0mo yr 13-UNDER CARRIAGE 19 I 2 FIRE ❑ ® U2 C c El F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y EQ N DUNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 6 I:, COM VEH ❑ ® U1 W FIRST CONTACT 11 ?A LC_5 •If Yes.See Sidebar z ELGIN IL 60120 0 1 0 DF93941 IL 2024 I 0 C IL D 0 3VW7S7AT9DM819549 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 982658771 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 11 / M 2 4 0 1 m / / #OCCS D 71 / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 CD 11 1 12,31 /2024 06 35 0 AM in a Work Zone? lgi N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 ❑ 26 28 12,31 ,2024 06 47 ®PM ❑Construction * 1 R 3 ❑ ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 3 z J ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Serafin.Steve.A. 11-709-A S1542-000052 12/31 /2024 06 51 lgl PM El Utility SLMT I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM o Nt 2 ❑ ARREST NAME Hayes. Lynda.A. 3-414 S1542-000054 12/31 /2024 07 00 ®PM El Unknown work zone type U1 30 2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1542 Chafe. Ethan 601 01 ,21 ,2025 09 00 ❑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 truckrtrailer -< ` ` --I -' I. INDICATE NORTH combination):or —I } �• - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C s; I © - } (example:shuttle or charter bus):or 0 r ` A Pi `� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0 } } I. transporting employees in the course of their employment(example:employee X r I \ nbr so:mac I transporter-usually a van type vehicle or passenger car):or w C I. I. __}----; - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. fn for direct compensation(example:large van used for specific purpose):or O L L____a____i 14 _ _ _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m —O placarding(example:placards will be displayed on the vehicle). ;p Unit s D S' CARRIER NAME ® 1 I I ADDRESS D I d w r I CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __; - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 Gray Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE