HomeMy WebLinkAbout2024-00063042 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00063042 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '�I
CLAYTON AVE Elgin ❑ RELATED ❑Y coN 10 02 2024 08:11 ❑AM ❑YES ®No u1 .<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW N
❑ FT/MI N E S W 'WITH VEHICLES INVLD El STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
❑DRIVER Ig PARKED ❑ORNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
/ / FOR DAMAGEDAREA(S) FRONT TOWED Ut
Dodge Ram ProMaster 2017 00-NONE 12 1 DUE TO CRASH 0 21 -
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE
®t 2 FIRE 0 ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 ® U2 m
O76-TOP 3
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN
r CITY PLATE NO. STATE YEAR POINT OF iI 6 it_ COM VEH 0 El 1
1- FIRST CONTACT 9 7. .FEAR._5 'If Yes,See Sidebar U1 0
Z 3396196B IL 2024
. ID VIN INSURANCE CO. EXPIRED
3C6TRVDG2HE538877 Farmers Insurance ❑Y ®N U2 1.1 I—
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y r Latine.Tamara. L. 187018117 1I—
m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER
o RESPONDER
II 890 CLAYTON AVE. ELGIN . IL.60123 (224)558-0331 VEHU 6)
❑DRIVER 0 PARKED 0 DRNERLESS ❑ PED ❑PEOAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 73
a 13-UNDER CARRIAGE 10 I 11 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR n
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN e 4 •Distraction Value U1 4
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POINT OF I
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_)1 8I_5 COM
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
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❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPONDER
YOQ NR Ut I
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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I I #OCCS D
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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 1 ® 1 1 1 10/02 /2024 08 38 ®pM in a Work Zone? ®N DIRP co
T 2 0
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 0
a
! / 0 PM El Construction *
(V 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
Q ARREST NAME Enoczelaya Elbir. Eder 11-601-Ax 1525000331 / / ❑PM\ 0 SLMT
o u 1 0CITATIONS •ISSUEDPENDING ROAD CLEARANCE TIME Utility
o N 0 0 SECTION CITATION NO. AM 30
2 0 ARREST NAME 10/02 /2024 09 30 ®PM 0 Unknown work zone type Ut
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 El1525-Nava.Oscar 501 334-Fries 10 1 22/2024 09 00 D RA Workers present? El
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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
• ADDITIONAL UNITS FORMS
' } A CMV is defined as any motor vehicle used to transport passengers or property and
1 . r r r r , , , , . r0 .
z
1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` ; ; ', ', ; ! i. ` ' ' a. ', ' I. ` r r r (example.shuttle or charter bus)-or 0
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----i-----a a a I t • : - -, I I + i } - t transporting employees in the course of their employment(example.employee 71
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
r 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) "0
1.
CARRIER NAME Z
' ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate ❑ Intrastate <
❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
•• , • Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
z
GVWR/GCWR —I
❑ <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles z
own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash% p
❑ 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
z
Form Number CJ
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? T
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
u 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't z
White
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE