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HomeMy WebLinkAbout2024-00063029 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 M IIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0035:3101* u, 1 U21 1 1 1 u, 7 U2 7 u, 1 1_12 1 u, 1 U2 1 4 11 u1 1 U2 1 *P 0 1 1 9 INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00063029 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 ® ❑ RELATED PRIVATE ❑Y ®N 10 02 2024 ❑AM ❑YES ®NO U1 RT20 WB Elgin mo /day/yr 07:23 ®PM FLOW CONDITION m • E050 ®!MI N 0 S W South State St COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 1 cn Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 01 / yr 2016 Nissan Sentra 00-NONE ©, © �/DUE TOCRASH ® ❑ 13-UNDER CARRIAGE 16 1 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 m M 2 5 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 I,.4 COM VEH 0 El 1 0 ~ ELGIN I L 60124 B 1 0 FIRST CONTACT 12 7_: __5 *lI Ves.See Sidebar U1 Z DZ75140 IL 2025 REAR TELEPHONE IL D 0 3N 1 AB7APXGY336826 Allstate ❑Y ®N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 802 359 831 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Provena St.Joseph ❑Y ❑ N 2 XI m E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL ❑EWES ❑Nuv ❑NOV ❑DV /1 9 9 3 Hyundai Santa Fe 2005 00-NONE i1_"j Q�,-_, DUE TO CRASH rg ❑ 2 x o Yr 13-UNDER CARRIAGE 10( i FIRE 0 ® U2 C li M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 .co. 4 COM VEH ❑ ® ut CO FIRST CONTACT 6 Ci,=Q •IfYes.SeeSidebar C ELGIN IL 60123 0 1 0 EW81656 IL 2025 I AR 0 N IL D 0 KM8SC13E450006781 None ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire CHOMOR.AMBER. M. None BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP ui = (UNIT) (SEAT( (DOB' (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 3 4 03 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ID 11 1 10,02 /2024 07 26 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ® 11 1 28 03 10,02 /2024 07 34 PM ® • ❑Construction >E en R 3 ❑ CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ❑AM ❑Maintenance U2 -a, ARREST NAME PATEL.JYANTIBHA!.S. 11-601 476000295 10/02/2024 07 40 0 PM o • SLMT u 1 ❑ 11 1 CITATIONS ISSUED 0 PENDING o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility Ti 2 ® 1 1 1 ARREST NAME Valdez-Chavez.Adrian.A. 11-601 476000294 10/02 /2024 08 10 0 PM El Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 476-Ramos.Clarissa 701 11 / 19,2024 09 00 0 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 -< i- }--_.r-_--; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 _ } (example:shuttle or charter bus):or C) X I- I- --I----; - transportingdgo lin the course of 5 or fewer he r emplrs oyment example:employee a contract ner X } } } employeesemployment m s transporter-usually a van type vehicle or passenger car):or c0 L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ,Zt D " CARRIER NAME Z gm. ADDRESS wra--r nnz-�al T. w C) CITY/STATE/ZIP g Not To Scale 1 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --4. - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes II 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' -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 Red Black 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE