HomeMy WebLinkAbout2024-00061301 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II II Olfi
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061301 VEHT
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg -n
S STATE ST ® ❑
Elgin RELATED ❑Y CON 09 24 2024 09:41 DAM ❑YES ®No u1 --‹
PRIVATE mo l day I yr ®PM FLOW CONDITION m
FT/MI N E S W LOCUST ST 'COUNTY PROPERTY El Y M N DOORING ❑y #OF MOTOR ❑SLOW 1 U)
❑ WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS 0
DI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGED AREA(S) FRONT TOWED Ut 0
NAME(LAST,FIRST,M) mo day yr
,0. / / Dodge Dakota 2000 00-NONE Q..O.,D, DUE TO CRASH El 13-UNDER CARRIAGE FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 El U2 2 m
SYSTEM IN n ENGAGED 0 15-OTHER 9 16-TOP 3 I
El El N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value g ALGN
r CITY PLATE NO. STATE YEAR POINT OF 8 . 6 • 4 COM VEH 0 El3
Z
ID VIN INSURANCE CO. EXPIRED 4
0 1 B7G L2ANXYS717923 Unknown ❑Y ®N U2 I—
m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn
0 JR THORNTON, LIONEL Unknown 2
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r
RESPONDER 102 S PARK BLVD.Streamwood . IL,60107 VEHU GI
L ❑Y ®N 99
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m / J FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Y N
s Sanchez Merino.Arturo,G. 1 2 2 4 2 0 0 0 Toyota Corolla 2024 00-NONE O' Dt DUE TO CRASH (ffi 0 2
Q, XI
v mo day yr .t3-UNDER CARRIAGE 10 Ij 2 FIRE ❑ ® u2 XI
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPUR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X
a 452 N GROVE ST 4 M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN II •Oistract(on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF
P RIST CNT ONTACT 12 7_'1 9 1_5 C•IOMesVSee Sidebar❑ ® U1
to
PEAR C
H Elgin IL 60120 A EN13475 IL 0 91
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)800-0471 S522-0070-0365 IL JTNC4MBE0R3223843 Progressive ❑y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 944759437 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
0 ri PONDER Same U1 =
(UNIT) (SEAT) (DOBI (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
1 3 11 /03/2000 F 9 8 B 1 0 Evelyn J. Compean I 317 BENT ST,ELGIN,IL,60120 R U2 mefused 996 m
(720)365-1397 ,
/ / #OCCS D
71
/ / u1 2 m
/ I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z
N ® 1 1 1 91 /41 /024 09 41 ®pM in a Work Zone? ®N DIRP co
1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5
2 ❑ 05 28 91 /41 /024 09 41 ®PM ❑Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
AM ❑Maintenance U2
a ARREST NAME 91 /41 /024 09 45 ®PM 1 ® 11 1 0 Utility SLMT
p U 0 CITATIONS ISSUED El SECTION CITATION NO. ROAD CLEARANCE TIME
p N AM 35
2 ElARREST NAME 91 /41 /024 11 02 El pm0 Unknown work zone type Ut
T •
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
El Y 35
1513-Mann, Nathaniel 701 - / / p 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.
r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
I I 0 ADDITIONAL UNITS FORMS
.
' } 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 Z
' r • ; i ; i- r r , , i INDICATE NORTH combination) or 'I
XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' L I i ! ( L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or
X
; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or w
' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver,
9 Po P 9 N
for direct compensation(example.large van used for specific purpose).or O
i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) 11
. `
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r r----, i
r - DO ILCC NO. m
U N XI
, Source of above Z
. 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
Form Number 0
M
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Maroon White
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X 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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE