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HomeMy WebLinkAbout2024-00059655 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets MI1111111111111 Milil H 111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003556922 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* 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 El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00059655 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE 0 Y ®N 09 17 2024 ❑AM ❑YES ®NO U1 RT20 WB HWY Elgin mo /day/yr 05:59 ®PM FLOW CONDITION Ill �0� O COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 !MI N S W Illinois Ave WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 (i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FROr4r TOWED U1 0©,I Acabal. Fred 0 4 / yr 13-UNDER CARRIAGE :: FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 50 M M 2 SY5 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S 4 COM VEH 0 El 10 Z ELGIN IL 60123 0 1 0 DW30645 IL FIRST CONTACT 12 T_: __s *uYes.See siaabar u1 0 REAR TELEPHONE IL D 0 WBANA53524B845995 NONE ®v ❑N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Acabal-Real.Anastacio NONE 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 XI x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES ❑ uv 0 ucv ❑Dv /1 9 9 7 Chevrolet Suburban 2003 00-NONE 'o,1 t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 C o —ay Yr 13-UNDER CARRIAGE Ti M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 9 POINT OF 8 i 4 COM VEH ❑ MI U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 6 O7 ,�=QOS •(ryes See Sidebar C Downers Grove IL 60515 0 1 0 DN64132 IL 2025 :EaR 0 to Z IL D 0 3GNGK26G83G213956 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 6308884041 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = iUNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 4 01 / , D / / 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 09/17 /2024 05 59 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � E, 2 0 28 15 / / 0 PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Acabal. Fredy 11-601 465-367 / / ❑PM ' j$[CITATIONS ISSUED 0PENDING • TIME • 0 Utility SLMT o NSECTION CITATION NO. ROAD CLEARANCE 0 AM 50 r 2 El ARREST NAME Acabal. Fredy 3-707 465-366 , / pM Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 20 465-Dorado.Ariana 401 334-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 INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or sorzaa,r ® 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O - ` - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w 4. Is used or designated to transport between 9 and 15 passengers,including (,/, -- -- 7\ - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O _a J t i. . i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p r,wn.zm _ 2:. CARRIER NAME Z Z ADDRESS 0 D Not To Scare I 0 . CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: _Redmons . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE