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HomeMy WebLinkAbout2024-00059055 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 M Hill $ 111111111 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0035:3097' u, 8 U21 3 4 1 U1 4 U2 1 U, 1 1_12 1 U, 1 U2 1 5 14 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202412024-00059055 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n PARK ST El In 02:19 ® ❑ RELATED ®Y 0 N 09 15 2024 ®AM YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MFT l MI N E S W DU N DEE AVE COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR El SLOW 1 cn ❑ 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 ❑ PED ❑Peon. ❑EouES ❑NOV ❑ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 O LopezGonzalez.Gabriel 1 0 / yr 13-UNDER CARRIAGE ©,I O'._Z FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n M 2 SYSTM 4 ❑Y ONE DUNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 1, 4 COM VEH 0 E! 1 0 F• Elgin I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *)(sees.See Sidebar U1 V. Z 9 ET86462 IL 2025 REAR TELEPHONE IL D 0 4T1 BG22K5YU656855 Kemper ❑Y ®N U2 31 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12RA000015274 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NOV ❑DV /1 9 8 9 Chevrolet Tahoe 2010' 00-NONE O Q1-_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 -iI�1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 11 7 _-5 •If Yes.See Sidebar 4 ELGIN IL 60123 0 1 0 EM61208 IL 2025 I 0 M IL D 0 1 G N MCAEOOAR244937 NIA ®V ❑N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same NIA BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 01 / :A / / UI 1 D / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 09,15 /2024 02 19 ®❑PM AM in a Work Zone? ®N DIRP D co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 0 05 25 / / 0 PM ❑Construction >E R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 -a, ARREST NAME Lopez Gonzalez.Gabriel 11-601-Ax 1518000314 / / El PM SLMT o U 1 ® 11 1 CITATIONS ISSUED 0 PENDINGTIME • ❑Utility o N SECTION CITATION NO. ROADCLEARANCE 0 AM 30 t 2 El ARREST NAME Lopez Gonzalez.Gabriel 11-709-A 1518000313 / / pM Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1 51 8-Vers etto. Elisa 301 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 combination)or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I - } r r r (example:shuttle or charter bus):or C 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier X I O - I. } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L -----}----; I -IIII I awes I - } } } used or designated to transport between 9 and 1 passengers,including the driver, C ill for direct compensation(example:large van used fors cific purpose):or O L L____a____. — _ _ _ _ _ l. ii. , 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m placarding(example:placards will be displayed on the vehicle). ;p CARRIER NAME Z ADDRESS Not To Scale I " T. CITY/STATE/ZIP. . ... . r i. i. i. i. 4. n MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 I 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 71 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 0 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Beige White 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE