HomeMy WebLinkAbout2024-00060812 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE I
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) Ell Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00060812 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 11
® ❑ RELATED PRIVATE ❑Y ®N 09 22 2024 ❑AM YES ®NO U1 -<
CONGDON AVE Elgin mo /day/yr 02:41 ®PM FLOW CONDITION m
010�!MI N E S ® Preston Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 Cl)
Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
yr 13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OD. O U2 2 <
M 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 ,6.TOP 3 DISTRACTED 0 0 _
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL _5 *uYes.SeeSidebar U1
4 COM VEH 0 j$J 1
0
Z FIRST CONTACT 12 7_
0 9 0 NONE IL 2012 ;REAR
_
TELEPHONE
IL Other JKAEXMF113A098800 Unknown El ❑N U2 m
.9 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 MANUELJUAREZ, Pedro Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 99 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 KCV 0 DV
�1 9 yr7 6 Chevrolet Suburban 2002 00-NONE O Qi-O DUE TO CRASH ❑ ® 1
0 13-UNDER CARRIAGE 10( 1: 2 FIRE 0 El U2 C
c ®
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 CO
Im
FIRST CONTACT 12 7�_, .6 •(ryes.See SidebarC
= ELGIN IL 60120 0 1 0 7573314 IL 2024 I 0
IL D 1 G N FK16Z42J 142467 Progressive ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
65 9 Same 23365222-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N ui =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 09(22 (2024 02 41 ®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 C)
Eri 2 ❑ 28 20
N 3 0 CITATIONS ISSUED 0 PENDING • ( 1 0 PM• ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a, ARREST NAME / / 0 PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2 0 ARREST NAME AM
7 ( r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 475-Williarhs, Brianna 201 334-Fries ( / D pM Workers present? ®N U2 30
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 ` --I -' r INDICATE NORTH combination):or —I
A 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I Al
r r (example:shuttle or charter bus):or X
I r i N 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- <_ --I-- --J. `
} } 1. 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 y
}--- ----; - } } } g po passen rs,includi the driver,
n4 for direct compensation(example:large van used for specific purpose):orCOnpO Pree O
a^`k— � i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a ,,— placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
i. i. 4- .I. 1 r . .. L. 1.. ...... ADDRESS
Not To Scale C I w
CITY/STATE/ZIP o
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-I. ------1 - USDOT NO. ILCC NO. m
XI
Source of above Z
. ❑ Yes 0 No ❑ Unknown A
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE