HomeMy WebLinkAbout2024-00061973 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
01101100 M 00 1 1110
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X06357M
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00061973 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
DUNDEE AVE El In 07:16
® ❑ RELATED ®Y ❑N 09 27 2024 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day /yr ®PM FLOW CONDITION M
FT!MI N E S W KIMBALL BALL ST COUNTY PROPERTY ❑Y ® N DOORING ®y #OF MOTOR 0 SLOW 99 Cl)
❑ Kane HIT ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST❑N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
1 2 /
yr
13-UNDER CARRIAGE 16 i 2 FIRE 0 0 <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 rn
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 COM VEH 0 0 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar U1
Z DX74566' IL 2025 REAR
TELEPHONE
IL D 2C3CDXHGOEH104636 None ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
1 52 1 Same None 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 ou
0 DRIVER 0 PARKED 0 DRIVERLESS RI FED 0 PEDAL 0 EWES 0 M/v 0 Ncv 0 DV
yr , 12 ._ C
0 13-UNDER CARRIAGE 10 i z FIRE ❑ ® U2 C
c M Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
❑ ❑ 0 UNK VEH. AT CRASH 99-UNKNOWN *OistraellonValue 4
POINT OF 8 i1�i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 C
FIRST CONTACT 1 Y _5 • •It Yes.See Sidebar
H Chicago IL 60601 C CO
Z
IL NIA ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 52 1 NIA BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 12 1 09,27 /2024 07 16 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 2 28 09,27 ,2024 07 16 ®PM ❑Construction >F
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ❑AM 0 Maintenance U2
a, ARREST NAME Guerra Manchame.Yeison.G. 11-1008 1513000474 09/27/2024 07 20 ®PM SLMT
oN 1 ® 1 1 1 lgi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
r 2 0 ARREST NAME Guerra Manchame.Yeison.G. 3-707 1513000475 09/27 /2024 07 39 ®PM El Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME co
❑AM Workers present? ❑Y
1513-Mann. Nathaniel 102 11 , 12/2024 01 30 ®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 -
` i•-- -- -' Dundse4Ave• r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L i I I - } (example:shuttle or charter bus):or
I r r ! I I 3. Is designed to carry 15 or fewer passengers and operated
�rated a contract carrier 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 L.__-a-_ _ _ _ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
r �.
__ - t i. i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
lambeil7S. 1 , , , , , CARRIER NAME Z
i ADDRESS D
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I iiI , , „ „ 4.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. ❑ Not in Comm./Other
Not Tb Scale I
O
USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 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: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE