HomeMy WebLinkAbout2024-00055398 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III I IIIIIII II 1111111111111111111111111111111111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035539 4
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15
0 NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and/or Tow Due To Crash YR 2024I2024-00055398 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg m
DUNDEE AVE ❑
Elgin RELATED ®" ❑" 09 01 2024 04:44 ®AM ❑ ®YES NO u1 ,�
PRIVATE mo /day I yr El PM FLOW CONDITION m
FT/MI N E S W 190 RAMP COUNTY PROPERTY El se ®" DOORING ❑y #OF MOTOR ❑SLOW U1
El 'WITH VEHICLES INVLD El STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0
I&DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑ WV ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FRONT TOWED U, O
.Victor, D. 0 1 / 2 3 /1 9 9 8 Chevrolet Equinox 2019 00-NONE ' .i O 0 DUE TO CRASH El ❑
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE i z FIRE ❑ ll <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ® ❑ U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
1213 E LONGVALLEY DR M ❑Y ®N ❑UNK VEH. 0 ATCRASH 99-UNKNOWN Distraction Value g ALGN =
CITY PLATE NO. STATE YEAR POINT OF O iI 6 jl O COM VEH 0 ® 1 O
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2G NAXTEV1 K6280888 NIA ❑Y ❑N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Y Escamilla,Sipriana N/A 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER 2146N GINGER CREEK DR, Palatine, IL,60074 VEHU
❑Y ®" 99 GI
❑DRIVER 0 PARKED 0 CRNERLESS 0 PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
13-UNDER CARRIAGE 10 I Ij Y FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR 1
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value U1 4
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61-5 CIO VEH
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
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(UNITE (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS Si WITNESS ONLY (NAME)/(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z
N 1 �� 43 2 09/01 /2024 04 44 ❑pM in a Work Zone? El DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C)
T 2 0 28 18
! / PM El Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
El AM ❑Maintenance U2
Q ARREST NAME Yanez-Escamilla,Victor, D. 6-206-A-21 1525000284 / / El PM SLMT
o N 1 [24 CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility 35
2 0 ARREST NAME Yanez-Escamilla,Victor, D. 6-101-A 1525000285 09/01 /2024 05 25 ®PM 0 Unknown work zone type U1
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0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 --❑ ®AM Workers present?
1525-Nava,Oscar 201 09 ,24/2024 09 00 0 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.
F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
; I A I _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
II I 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I combination) or
Not TO Scale r NDICATE NORTHXI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
-I ', d i -` ` r r r (example.shuttle or charter bus)-or n
---- ----% 4 1 I -i - i transporting employeeed to sl5 or fewer in the course their employrs and ment(example�emact ployeerier M
a \ f transporter-usually a van type vehicle or passenger car).or w
C
' 4 ) I _i i i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver,
I ) ; Vr11 r for direct compensation(example large van used for specific purpose).or O
L_____-____4 ; , 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) XI
CARRIER NAME Z
I
ADDRESS
r.
• CITY/STATE/ZIP
r , ,
MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not m Comm./Govt. Not mComm/Other
ILCC NO
r ,
USDOT NO. .
xi
, Source of above Z
. If Yes Name on placard 0
4 digit UN NO. 1 digit Hazard class No
73
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown D
Did Carrier Safety Regulations MCS)violation contribute to the crash
❑ Yes 0 No ❑ Unknown A
C
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
Form Number 0
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft Z
Silver
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE