HomeMy WebLinkAbout2024-00058402 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 O
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00058402 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED 0 Y ®N 09 12 2024 ❑AM ❑YES ®NO U1 -<
DUNDEE AVE Elgin 03:06
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
0 !MI 0E S W KeepAveCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl)
E05 ® Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 0NAME(LAST,FIRST,M) Garcia.Jeff mo 0 9 /
13-UNDER CARRIAGE 10 , 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 5 SYTM❑Y OS NE UNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER9 76•TOP 3 `Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il 4 COM VEH 0 j$J 1 0
~ RollingMeadows IL 60008 0 1 0 FIRST CONTACT 12 7_; _5 *IIYes.SeeSidebar U1
ZQ652903 IL 2025 Isui
TELEPHONE
IL D 3N1AB7AP9HY336754 Gieco ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 6124825123 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused 0 Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 i uv
�1 9 6 3 International l$�l�r Corp. 2005 00-NONE 0" 12' _• , DUE TO CRASH ❑ ® 14
0 Yr 13-UNDER CARRIAGE 10 i 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *OistractlonValue 9 0
POINT OF s i 4 COM VEH ® ❑ U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:._ C
FIRST CONTACT 11 7 —r_5 •If Yes.See Sidebar
— Streamwood IL 60107 0 1 0 38862TV IL 2024 I 0
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IL A 7 1 HTTVSAT15J033807 Union Insurance Comapny ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Chicago Stone Compan CPA3276628 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / M 2 5 0 1 0
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/ / #OCCS D
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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 ® 11 1 91 ,21 ,024 03 06 ®FM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 06 + ) 0 PM ❑Construction
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Z3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
o1 ® 11 1 ARREST NAME Garcia.Jeff 11-906 1534000062 , / El PM SLMT
S' N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
AM
r 2 El ARREST NAME / / ❑❑PM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1534-Santiago.Jorge 201 334-Fries 10 , 15,2024 01 30 ®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- }__-_r_-_-; \ combination):or —I
lBeef?Ville INDICATE NORTH p1
10557Dundee?Ave C
` BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
r r r (example:shuttle or charter bus):or 0
L L A 3. is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- } } } transporting employees in the course of their employment(example:employee X
I,v transporter-usually a van type vehicle or passenger car):or co
L L.___a____'' I 11
- - I. } } } •4. Is used or designated to transport between9and15passengers,includingthedriver. C
for direct compensation(example:large van used for specific purpose):or O
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Dun Is?A1 Unit i. < . ,_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ;D
:- I- ":" 1 II [ 0 , : :. ,__ __:.
CARRIER NAME Z
Not To Scale ADDRESS O
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CITY/STATE/ZIP I
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MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
USDOT NO. ILCC NO. m
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
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
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Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE