HomeMy WebLinkAbout2024-00060513 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III I IIIIIII II 11111111111 110111111111 lUll 1111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003569056
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
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El NOT ON S
VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00060513 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
BODE RD ®gin El
❑Y coN 09 21 2024 03:32 ®AM ❑YES ®No U1 .<
PRIVATE mo /day/yr ❑PM FLOW CONDITION m
0 'COUNTY PROPERTY El ®N DOORING 0 Y #OF MOTOR ❑SLOW CI)
®/MI N OE S W Fawn Ln 'WITH VEHICLES INVLD El STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg ORA/ER ❑ PARKED ❑DRIVERLESS ❑ PEn ❑PEDAL ❑EOUES 0 AIN 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FRONT TOWED U,
NAME(LAST,FIRST,M) ,J. mo O
General Motor-terrain2017 00-NONE DUE TO CRASH 21
1 1 / day / yr " 0O ❑
,3-UNDERCARRIAGE 10i z FIRE 0 1l <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 m
108 M U LFO R D DR M ❑Y ISYNM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH 0 ® 1 0
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t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
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NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 Xi
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a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value Ut 0 -
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N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.1I 6 I_S CIO MVSee Sidebar
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
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(UNITE (SEAT) ;DOB) ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS),ITELEPHONEI {EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z
N ® 20 1 09,21 /2024 03 34 ❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ®AM Ut 7
s 2 ❑ 20 21 09,21 /2024 03 34 ❑PM ❑Construction *
c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
®AM ❑Maintenance U2
ARREST NAME OrOZCO,Jose,J. 11-708 1512401 09/21 /2024 03 40 ❑PM SLMT
o U ❑ ®CITATIONS ISSUED 0 PENDING ROAD CLEARANCE TIME 0 Utility
2 NSECTION CITATION NO. AM 35
2 ❑ ARREST NAME 0rozco"Jose.J. 3-707 1512402 09/21 /2024 04 00 El RA0 Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
2 3 ❑ 1512-Juarez-Huichapan,Juan 200 - 11 , 12/2024 01 30 0 PM 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.
_ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
: ' (1!) 0
_� r A CMV is defined as any motor vehicle used to transport passengers or property and.
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
r 1 i combination) or
INDICATE NORTH ,Z:1
Nat To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I 1 , i -` ` r r r (example.shuttle or charter bus)-or 0
S
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_----....---% -i } - i transporting employees in the course of their employment(example.employee ,3
transporter-usually a van type vehicle or passenger car).or w
i_____A____: : Ftirrn4Ln r 1 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose).or O
( --1 i ' ` t poany (HAZMAT) requiresm
y 5 Is any vehicle used to transport hazardous material HAZMAT that rn
placarding(example placards will be displayed on the vehicle) 71
T.
``-, % CARRIER NAME Z
` `4 t ADDRESS 0
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® CITY/STATE/ZIP
no
I '7` MOTOR CARR.ID ❑ Interstate ❑ Intrastate -
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0 Not in Comm./Govt. El Not in Comm./Other
' USDOT NO. ILCC NO. CmXI
, Source of above Z
_ own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown g
Did Carrier Safety Regulations(MCS)violation contribute to the crash? O
❑ Yes No ❑ Unknown C
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No :
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
2
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
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TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
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_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE