HomeMy WebLinkAbout2024-00060558 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111111101101111111110 I
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0035609888*
u, 9 U2 1 1 1 U199 U2 1 U1 99 U2 U1 99 U2 99 1 9 Ut 1 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ID ON SCENE •
7
[23 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00060558 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1
CAPITAL ST ® ❑
Elgin RELATED ❑Y coN 09 21 2024 10_38 ®AM ❑YES ®No u1 ,-<
PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ®N DOORING 0 Y #OF MOTOR ❑SLOW 3 Cl)
®2 ®/MI N 0 S W Randall Rd 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0
D4 ORNER ❑ PARKED 0 ERNERLESS ❑ PEO 0 PEDAL 0 EOUES 0 NIA/ 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
.0. Unknown Unknown DO-NONE 11 12 i' , DUE TO CRASH 021
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10) 2 FIRE ❑ 1l <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 El U2 m
9 16-TOP 3
r / ❑Y ❑N ❑UNK VEH. AT CRASH " POINT OFO 8 � 4 COM VIEH ion Value ❑ ElALGN
CITY PLATE NO. STATE YEAR 99 il} 10
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ID VIN INSURANCE CO. EXPIRED 1
unknown ❑Y ❑N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR I—
Y r 99 9 Same unknown 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER S VEHU
L ❑Y ❑N Same 99 0
0 DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
NAME(LAST,FIRST,M) mo day yr Nissan Quest 2016 00-NONE 1t' 12 Y DUE TO CRASH ❑ 21 2 -I
10 13-UNDER CARRIAGE j Ij 2 FIRE ❑ ® U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 15-TOP 3
❑Y ® N 'DUNK VEH. AT CRASH 99-UNKNOWN O 4 •Distraction Value g U1 9
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® to
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1— FIRST CONTACT 8 7. t-6 .5 •If Yes,See Sidebar
CG54757 IL 2025 R 0 C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
JN8AE2KP4G9154720 American Family ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST.M) POLICY NUMBER 1 I
99 9 Machuca Camargo-Guillermin 252059040990FPPAII BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
Y ONR 933 COOKANE AVE. ELGIN . IL•60120 (847)660-0310 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)!{ADDRESS)!{TELEPHONE) (EMS) (HOSPITAL) n
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/ I 0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 18 5 09/21 /2024 10 38 ❑pM in a Work Zone? El DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 0
T 2 ❑ 18 18
! / ❑PM ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ElAM El Maintenance U2 3
Q 1 ® 11 5 ARREST NAME / / ❑PM 0 Utility SLMT
0 U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8AM 10
2 ❑ ARREST NAME 1 / ppl ❑Unknown work zone type Ut
T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 0 AM Workers present? El Y 10
547 Homeier,William 275-Engelke / ❑PM ElN 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.
0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
; _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r } '. i ; i combination) or —I
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} i I d i -` ` r r r (example.shuttle or charter bus)-or 0
03 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
-----;-----+ + 14407Cepllorost -i } } } transporting employees in the course of their employment(example.employee 7,
transporter-usually a van type vehicle or passenger car).or w
i_____A____: : i + Not To Scots _: i r 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
L____-:_____; i ; 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
I.
CARRIER NAME Z
' D i. .. ADDRESS 0
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I I I I I I I I J •
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• CITY/STATE/ZIP
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MOTOR CARR ID ❑ Interstate El Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r , ^ USDOT NO. ILCC NO.
, Source of above Z
. Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No -
MCS El Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number D
m
XI
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
D
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z
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U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE