HomeMy WebLinkAbout2024-00060669 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 IR I 101011100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo0a68272
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202412024-00080869 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
2000 N RANDALL RD El11:17
® ❑ RELATED ❑Y ®N 12 27 2024 ❑AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD IN STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑uuv ❑!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0
FOR DAMAGED AREA(S) FTOWED U1 Q
NAME(LAST,FIRST,M) Unknown.O. mo ! ! yr Ford F150 00-NONE 11;.FROM O I"_t DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 I<rl
SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3
M 9 9 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL S !i, COM VEH 0 Ea 1 0
~ 0 9 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE
IL Other Unknown ❑Y ❑N U2 I'
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same Unknown 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 3 0
99
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EWES 0 ivy 0 Ncv 0 DV
Yr
!2 O O 0 Subaru WRX 2017 oo-NONE 11 12'-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 101 2
FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 3 X
❑Y El N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
POINT OF 8 i 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 6 7 -�ri •If Yes.See Sidebar C
Algonquin IL 60102 0 1 0 G I NGSTI IL I0
IL JF1VA2M67H9813782 Cincinati Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same A010718286 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 3 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,27 l2024 11 17 ®PM AM in a Work Zone? ®N DIRP D
co
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
57 2 0 28 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
z
—a, ARREST NAME / / ❑PM '
o N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
50
t 2 0 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 901 — r ! ❑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 truck trailer -<
r }-- . combination):or
--r----, I - r INDICATE NORTH 51
I ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I _ } (example:shuttle or charter bus):or 0
I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
< <.---a_._.� 1
} I- } transporting employee �I IIn the course of their employment(example:employee
Nl I I w transporter-usually a van type vehicle or passenger car):or co
L }----------; - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
% for direct compensation(example:large van used for specific purpose):or 0
L ——— — — t i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
r m
rarrmll7116 ,, placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
I 1 - . . ADDRESS D
I I 0
CITY/STATE/ZIP g
I - MOTOR CARR.ID 0 Interstate El Intrastate
0
. ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
v
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
Tan Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE