HomeMy WebLinkAbout2024-00058819 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 M U I 0 II II 110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00058819 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED PRIVATE 0 Y ®N 09 14 2024 El AM ❑YES El NO U1 -<
ERIE ST Elgin mo /day/yr 01:43 ❑PM FLOW CONDITION m
030 ®!MI N E S ® South Aldine St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
18:DRIVER (] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM�TOWED U1 Q
NAME(LAST,FIRST,M) Cu EVAS SI LVA. Dario m / 1 9 2 o 8 201 2 yr Nissan Rogue 00-NONE 11_' Q T 71 DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 i 2 O FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 COM VEH 0 Ea 1 O
F• Elgin I L 601 23 0 1 0 FIRST CONTACT 1 7_'mR--5 *lives.See Sidebar U1
Z 9 AE15259 IL 2025 E
TELEPHONE
IL D 0 JN8AS5MV8CW383838 Alteza Insurance ®Y ❑N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Cardoso Hernandez. Maria. E. 12AU001536012 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr .I ,y -, DUE TO CRASH ❑ ® 1 7:/o _ 13-UNDER CARRIAGE 10;1 !. 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El SPDR C)
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3
❑Y ElN ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 9 i �.. to
COM VEH ❑ ® U1
F,,, FIRST CONTACT 7 O7 :_�4a�1=5 •If Yes,See Sidebar
EE40072 IL 2025 REAR0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G1 PA5SH4D7214023 American Alliance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Martinez. Leslie. K. ILAA-0879625-02 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
Ui =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 09,14 ,2024 01 44 gi 0 PM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 0 08 19 , , ❑PM 0 Construction >F
R 3 0 ZSI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME CUEVAS SILVA. Dario 6-101 751565 , r El Pm SLMT
ljg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N AM 30
T 2 ElARREST NAME CUEVAS SILVA. Dario 11-709-A 751564 , , 0 pM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
447-Collins, Dominique 601 10 ,21 ,2024 09 00 ❑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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
} s. Avg 0 - } r r ,. (example:shuttle or charter bus):or 0
L L.___A.._.� Nof To Scale! _ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier i O
, i } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - •} } } g po passen rs,includi the driver,
� for direct compensation(example:large van used for specific purpose):or
cj
L i.--_-a-.... _ _ i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Ede 81 ui7 unMt , . ,
placarding(example:placards will be displayed on the vehicle). XI
T —ICARRIER NAME Z
ADDRESS 0
V)
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;____Y_._- - USDOT NO. ILCC NO. rn
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE