HomeMy WebLinkAbout2024-00057450 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40354&54S
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00057450 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
N MCLEAN BLVD Elgin 01:23
® ❑ RELATED 0 Y ®N 09 09 2024 12,— ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W LARKIN AVE COUNTY ❑ ®PROPERTY Y N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPff TOWED U1 0
Martinez. Elsa 1 2 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 M
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER O9 16.70P 3 _
0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� ii,4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 C 1 0 FIRST CONTACT 9 O7 R--5 *If Yes.See Sidecar U1 0
ZDU93239 IL 2025
TELEPHONE
IL D 2T1 LR32E53C088129 State Farm ❑Y Il N U2 51 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 2288747-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y 0 N 2 G0)
m E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 row 0 NOV ❑ CIRCLE NUMBER(S) U1
Dv
yr Ford Expedition 2022 00-NONE O, 0i.O DUETOCRASH ❑ ® 5 x
o 13-UNDER CARRIAGE 10,i I.. 2 FIRE 0 ® U2 C
c
M 2 4SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 0 X
0 Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i S 1' 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y��_, =5 •(ryes.See Sidebar C
ELGIN IL 60120 0 1 0 M242200 IL 2025 I 0 fp
IL B 1 FMJ K1 JTXN EA56238 Charter Oak Fire Ins Co ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
City of Elgin.City 8109160P901 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((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 4 09/09 /2024 01 23 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 0 2 99 + / 0 PM- 0 Construction X
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
a ® 11 4 ARREST NAME Martinez. Elsa 11-907-A 414-947 / / ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
AM
r 2 ElARREST NAME 1 / El pM ElUnknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
414-Lara. Saul 602 272-Bajak 10 , 15/2024 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 truck trailer -<
- -----'-----; I I
I - ) INDICATE
ARROW NORTH
combination):or p0
2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
I — - 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
/va ra sow
<_-------- ; I y I } } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or C
L •:. __}----; I - } } } •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 O
< <-- - — _ t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires III
- �`----' Q
' placarding(example:placards will be displayed on the vehicle). ,Zmt
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.� - CARRIER NAME 0
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w I _ ADDRESS D
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CITY/STATE/ZIP C)
- i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
;____Y____1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No =
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
a
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
White Red
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE