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HomeMy WebLinkAbout2024-00060684 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 M U I 0 fll 10 DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003562594 u, 1 U2 1 1 1 U1 4 U2 U, 1 U2 u, 2 u2 4 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT E) A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-S1,500 ®ON SCENE 16 VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00060684 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ®Y 0 N 09 21 2024 DAM ❑YES ®NO U1 —< BIG TIMBER RD Elgin mo /day/yr 10:09 ®PM FLOW CONDITION m 50 ® COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl) !MI N E S W State St WITH VEHICLES INVLD 0 STOPPED U2 --I IDAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 1 / yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m F 2 4 SY❑Y ®N SE❑UNK VEH. AT CRASM IN n H 99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1i.4 COM VEH 0 El 1 O ZE LG I N IL 60123 0 1 0 EV99358 IL FIRST CONTACT 12 7 •; __5 *If Yes.See Sidebar U1 TELEPHONE UNK. Other 0 1 FAFP31 N56W218805 Direct Auto ❑Y ®N U2 r .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Rincones. Luis PAI L00125497 1 r 5HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMy 0 NOV 0 DV yr 12 _ X1 o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 El El SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 `Oistrac) n Value 3 - -.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=5 Cto •IO e1sVSee SidebarEH ❑ 0 U1 C F` pEAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEATI (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 43 4 09,21 r2024 10 09 ®PM 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 ❑ 28 99 ! r ❑PM• ❑Construction R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 —a, ARREST NAME Caruci Arias.Alejandro.A. 11-601 S1502-000252 r ! El PM SLMT o N 1 ❑ BI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility AM 45 t 2 El ARREST NAME Caruci Arias.Alejandro.A. 6-101-A S1502-000251 ! r 0 pM ❑Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y 2 3 ❑ 1502-Camiacho. Fernando 501 280-Marabillas 10 , 15/2024 01 30 ®PM Am Workers present? ®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•---, 0 J I I I - • A CMV is defined as any motor vehicle used to transport passengers or property and: Z StALe St 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< } }--_.r-_--; I I r combination):or 0 INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n _ } (example:shuttle or charter bus):or 0 LA 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O Big?Timber4Rd - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L L.__-a-_ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including w} } for direct compensation(example:large van used for specificpurpose):or [he driver, _ Pe ( P 9 Pe or L -a-___. - l. i i. i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •u placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ,. � 1 - - __ 1 ADDRESS 0 T. rA C) -- CITY/STATE/ZIP g Not To Scale J MOTOR CARR.ID 0 Interstate ❑ Intrastate T I II ❑ Not in Comm./Govt. Not in Comm./Other 0 .:- ‘:- -- - --4. I I • . . . USDOT NO. ILCC NO. 0 73 Source of above 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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z ill TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Bronze u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. _Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE