HomeMy WebLinkAbout2024-00061432 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.5000 NOT ON S®ON SCENE •
14
VEHICLE/PROPERTY Ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061432 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'TI
N STATE ST ®gin ❑ RELATED ❑Y coN 09 25 2024 02:00 ❑AM El ®No u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
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) PEDALCYCUST El ® FREE FLOW # LNS O
tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 05 n
FOR DAMAGEDAREA(S) FRONT TOWED U1
Ford Explorer 1 9 8 92004 00-NONE 1 DUE TO CRASH 0 21
NAME(LAST,FIRST,M) .A. mo 0 3 / day J yr P 11- 12
13-UNDER CARRIAGE 10 1 2 FIRE 0
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 05 m
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
2500 WATERMARK TER 101 M ❑Y ®N DUNK VEH. 0 ATCRASH 0 99-UNKNOWN Distraction Value 9 ALGN I
r CITY PLATE NO. STATE YEAR POINT OF ®ii 6 `O COM VEH 0 El 1 n
F FIRST CONTACT 5 O7-:I ]-OS 'Yves,See Sidebar U1 0
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1 FMZU73K44ZA09363 INSURE ON THE SPOT ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Same ILT5525044 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >
'' RESPONDER Same VEHU
L ❑Y ®N 2 G1
' ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / J FOR DAMAGED AREA(S) FRONT TOWED
s GAYTAN- KAYLA 0 9 2 9 2 0 0 3 Toyota Tacoma 2010 00-NONE O j O ❑ ® 2 Xi
NAME(LAST,FIRST,M) mo day yr 9 Oi! 2 FIRE ❑ MI U2 C
v 13-UNDER CARRIAGE
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 ® SPOR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X
a 328 WHEELOCK ST F ❑Y Igl N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POEH
FIRST CNT OONTACT 12 7. . 6 ` .5 •CIrOVeeM VSee Sidebar ® U1
to
H ELGIN IL 60123 0 2909979E IL 2024 REAR
0 C/1
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)387-8020 G350-5000-3877 IL D 3TMLU4EN7AM050180 AMERICAN FAMILY ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 GAYTAN. MILTON 410711420866 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
328 WHEELOCK ST. ELGIN . IL•60123 (224)587-2426 U1 =
(UNIT( (SEAT) ;DOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE) (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 ® 11 1 09/25 /2024 02 17 ®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 U1 7
a
2 ❑ 2 28 / / 0 PM ❑Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
Q ARREST NAME Graves.Zachary.A. 11-901 1506-279 / / El Pm SLMT
® 1 1 1 •' 0 Utility
p U 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N II AM 45
2 ❑ ARREST NAME , / ptil ❑Unknown work zone type Ut
2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1506-Nunez. Maria 501 334-Fries 11 , 12/2024 09 00 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.
_ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
; _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
D
Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
, r 1 i ; i INDICATE NORTH combination) or
57
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 0
501 i [
Nor To SoW ;
• j 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
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} } } transporting employees in the course of their employment(example employee 71
L transporter-usually a van type vehicle or passenger car).or w
�____A____: : , — — — —- _� : i r i 4 Is used or designated to transport between 9and 15 passengers,including the driver, N
ect
sation( xample.
van used
r. i } i 5 r Is'rany vehicle usedtotransportla nehazardous for
matenalspecific
(HAZMAT))that requires O
\ rn
placarding(example placards will be any
on the vehicle) 71
— — — —
CARRIER NAME Z
. ' uroTATSWT Ii. ADDRESS 0
N
'• CITY/STATE/ZIP 0
, ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. Not in Comm./Other
USDOT NO. ILCC NO.
• , Source of above Z
. ❑ Yes 0 No ❑ Unknown A
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 5
Z
Form Number 0
_ m
— xi
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
CA
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ o
u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Silver Brown
-
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE XI DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO
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