HomeMy WebLinkAbout2024-00054811 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 010 III Ifi
IIIIIII II 11111111IllIllHl 101 11111010111 II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035555�4,
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1
0 NOT ON
VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) Ill B Injury and JorTow Due To Crash YR 2024I2024-00054811 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71
N COMMONWEALTH AVE El ❑ 'gin RELATED " ❑" 08 29 2024 05:53 ❑AM ❑YES ®NO U1 -•<
PRIVATE mo l day I yr ®PM FLOW CONDITION m
FT/MI N E S W LAWRENCE
) Kane HIT&RUN 23Y 0 N PEDALCYCUST®N ❑ FREE FLOW # LNS O
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES 0 NNv ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Q n
FOR DAMAGED AREA(S) FRONT TOWED Ut
. Unknown / / Lexus GS300 2008 00-NONE Q..O.,D, DUE TO CRASH El NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 1144-TOTAL(ALL) 10 z DISTRACTED 0 I U2 0 m
IA
SYUNKNO UNKNOWN ❑Y ®SM NE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN THER 916-TOP S ,Distraction Value g ALGN ..
T. CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH 0 ® 1 0
FIRST CONTACT 12 7_.1 :.5 ^Yves,See Sidebar U1
Z
ID VIN INSURANCE CO. EXPIRED 1
15 JTHCE96S880019532 Unknown ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Robledo.Anthony. R. Unknow 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r
L 0 y°®EN 2030 MONDAY DR. ELGIN , IL.60123 (847)660-0116 VEHU 0
5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 99 m
m / J FOR DAMAGED AREA(S) FRONT TOWED Y N
s Bedolla-Andres, B. 0 1 1 2 1 9 8 0 General MotorAd ip 2014 00-NONE O' D DUE TOCRASH IN 0 2 XI
NAME(LAST,FIRST,M) mo day yr Q,
✓ t3-UNDER CARRIAGE 10 Ij 2 FIRE ❑ ® U2 C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IZI SPDR 0
Y
E 401 LUCILLE AVE M SYSTEM IN 0 ENGAGED Q ®-OTHER 9 16-TOP 3
❑ ® ❑UNK VEH. AT CRASH 99-UNKNOWN 8 II 4 ^Distraction Value g U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF
FIRST CNT ONTACT 12 7_'1 6 1_S C•IOMesVSee Sidebar
al
H ELGIN IL 60120 0 DP42383 IL MAR 0 PI
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)846-3465 UNKNOWN IL D 0 1GKKVTKD2EJ125454 None ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Same None BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
Y NEl R Same Ut =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
/ I U2 996 r
m
- #OCCS y
/ / U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ElY U2 Z
N 23 11 1 08,29 ,2024 05 53 ®pm in a Work Zone? ®N DIRP CO
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: Ut 3 C)
T 2 ® 18 1 23 28 ! / ❑AM 0 PM ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance uz
Q •® 11 4 ARREST NAME / / ❑PM 0 Utility SLMT
p U1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
g 8 AM 30
¢ I 2 ❑ ARREST NAME , I ptil 0 Unknown work zone type U1
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
485-Quintana,Josue 601 334-Fries , , ❑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.
14IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
I _� A CMV is defined as any motor vehicle used to transport passengers or property and. Z
' I I MI 0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
, r } 1 i ; mil; combination) or
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} i ', ', i ` ,A ! ` r r r (example shuttle or charter bus)-or 0
I
N ; ; 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
---- ---- f } } } transporting employees in the course of their employment(example employee 0
-usually a van
vehicle or
ca
A J Not To Scale ` i r i 4 transporter sedor des gnated to rpansport between 9 agar 15rpassengers,including the dBver, C
for direct compensation(example:large van used for specific purpose).or O
L--1---1
II i ; i. i } 1any 5 Is any vehicle used to transport hazardous material(HAZMAT)that requires
rn
I rn
placarding(example placards will be displayed on the vehicle) 71
T.
r' /� CARRIER NAME
1 I 1 l tav'e'°'1'�°'� .. ADDRESS 'n
N
• CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate ❑ Intrastate
r ,
0 Not in Comm./Govt. Not in Comm./Other Q
❑ C
r- -'-- i i I r ^ USDOT NO. ILCC NO. m
, Source of above Z
. MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
2
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
' TRAILER VIN 1 m
CA
LOCAL USE ONLY TRAILER VIN 2 m
D
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Blue,Light Black
u 1 TOWED - - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO:
DUE TO ❑ Redmons/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE