HomeMy WebLinkAbout2024-00059444 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets Mill Mil
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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 215501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00059444 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y ❑N 09 16 2024 DAM ❑YES ®NO U1 -<
N RANDALL RD Elgin11:28
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 RED 0 PEDAL 0 EouES 0 NOV 0!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 7 /
yr 13-UNDER CARRIAGE 10l 12 �. 2 FIRE ❑ ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 M
F 2 4 El ®SNE❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UUNKNOWN 9 16-TOPO `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH ID El 1 00
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ELGIN IL 60120 0 1 0 FIRST CONTACT 3 7_; __5 *IIYes.See Sidebar U1
Z 28097798 IL 2025 REAR
TELEPHONE
IL D 1 C6RR7LG7GS130734 State Farm ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Pena. Francisco 3395802-sfp-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑I vv 0 CIRCLE NUMBER(S) U1
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0mo 13-UNDER CARRIAGE FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracti n Value 9
6 i1 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 L -
COM VEH 0 ® U1 co
FIRST CONTACT 1 Y _, _5 •
Z Schaumburg I L 60173 0 1 0 DR54668 I L 2024 REARIfYes,See Sidebar 0 N
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IL D 1 G 1 J F52F347151163 ESURANCE ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
South Elgin Fire Same PAI L-5890709 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (D051 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 5 01 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El
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N 1 ® 11 4 09,16 /2024 11 30 0 pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 2 99 09,16 ,2024 11 29 ®PM ElConstruction >F
R 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM 0 Maintenance U2
-a, ARREST NAME Barreno Elias.Santa Ana 11-901-A 1517000338 09/16/2024 11 29 Igi PM SLMT
oN ® 11 4 •lgi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
t 2 El ARREST NAME Barreno Elias.Santa Ana 4 1517000339 09/17 /2024 12 10 0 PM 0 Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1517-Le Cates. Brittany 502 368-Davenport 10 , 15/2024 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 truck trailer -<
` ` ' ' r INDICATE NORTH cot
or p0
RonckdriRd,4Bpin BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
ti - } (example:shuttle or charter bus):or
X
L A ■ - lE 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
■ = ® - }} } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L____a____. -- -- _ 4. Is used ordesi natedtotrans rt between 9 and 15passengers,includirgthedriver. C
- } } for direct compensation(example:large van used for speific purose):or
L i.____a____. _ i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
o rr — placarding(example:placards will be displayed on the vehicle). X)I,• CARRIER NAME
Bled rnd. �1 _ ADDRESS O
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
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. Form Number m
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Red
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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 ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE