HomeMy WebLinkAbout2024-00058130 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00356267 2
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00058130 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
855 S RANDALL RD Elgin03:58
® ❑ RELATED ❑Y ®N 09 11 2024 ❑AM ❑YES El NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl)
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Nissan Murano 2009 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) U2 O <
M 9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 DISTRACTED 0 0 _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH ❑ j$J 1 0
I• 0 9 0 FIRST CONTACT 99 7_; __5 *IIYes.See&debar U1
ZEK91650 IL 2024 REAR
TELEPHONE
IL Other JN8AZ18W49W129107 NIA ❑Y 0 N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NIA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row
yr 12 _
0 13-UNDER CARRIAGE 10 1 2 FIRE ID El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 9 16.TOP 3 DISTRACTED 0 ® SPDR n
0 0
SYSTEM IN ENGAGED 15-OTHER
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN * 9 0 Oistrac on Value U1
POINT OF 8 {I '4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 IL_ COM VEH ❑ ® CO
FIRST CONTACT 6 Y__{_O ._5 •If Yes,See Sidebar
H EA69816 IL 2025 REAR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 V2XR2CA9KC570034 Gieco ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Mojica.Yensenia 4439937527 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 09/11 12024 04 02 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 30 99
N 3 0 CITATIONS ISSUED 0 PENDING + / 0 PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
z
-a, ARREST NAME / / PM '
o N ER11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
10
T 2 ARREST NAME AM
T / / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D 1534-Santiago.Jorge 702 C1 22-G ajewski / / ❑❑PM Am Workers present? ®N U2 10
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 -<
c ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
r } } } transporting employees In the course of their employment(example:employee I °
I transporter-usually a van type vehicle or passenger car):or co
L L.___a____J. •, _ - Not To Scale I - } } } 4. Is used or designated to transport betweenpassengers,includingthedriver,
I I for direct compensation(example:large van used fors specific purose):or
O
L L--_-a----. _ L i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
m
I 2#
CARRIER NAME Z
I ADDRESS 0
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ 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
. 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 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
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: 1 TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE