HomeMy WebLinkAbout2024-00081606 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00081606 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
2535 WATERMARK TER Elgin02:22
® ❑ RELATED ❑y ®N 12 31 2024 DAM ❑YES El NO U1
PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
_
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 15 '
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH 0 NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑ IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
9 3 SYSTEM IN a ENGAGED 9 15-OTHER 9 16.TOP 3 0
_
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN $ 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 ji COM VEH 0 gI 1 00
H 0 1 0 FIRST CONTACT 99 7_i __5 *lI Yea.See Sidebar U1
ZUNKNOWN Unknown REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNKNOWN Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV
yr BMW X3 2021 00-NONE N_ 12..4:J DUETO CRASH 0 ® 1 X/
o 13-UNDER CARRIAGE I 1.J FIRE 0 ® U2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 f O DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 X
a ❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF s "4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S ,._ C. VEH ❑ ® CO
FIRST CONTACT 1 Y _, _5 •IfYes.See Sidebar
H AE27415 IL 2025 RFJ 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5UXTY9C07M9F33343 Allstate 0 Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
PATEL.SHAURYA. P. 975186772 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 12,31 /2024 02 45 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 26 18
N 3 0 0 CITATIONS ISSUED 0 PENDING / 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
z
-a, ARREST NAME / / 0 PM
I ® 1 1 5 ❑CITATIONS ISSUED PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
ElUtilit y
t 2 0 ARREST NAME 1 2 r 31 /2024 03 27 ®PM El Unknown work zone type U1 20
x 0 AM
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 20
476-Ramos.Clarissa 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.
.. .. , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r ,
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
I P�7Webr^•K+TM combination):or
r }----r----, - r INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I. } } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
C
} } } for direct compensation(example:large van used for speific purose):or 0
--I-- -I - t i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
placarding(example:placards will be displayed on the vehicle). XI
-I
CARRIER NAME Z
ADDRESS 0
V)
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
TNot To Scale ) ❑ Not in Comm./Govt. Not in Comm./Other 0
�------ USDOT NO. ILCC NO. rn
XI
Source of above Z
. ❑ 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 :
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
v
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
White
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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE