HomeMy WebLinkAbout2024-00063491 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;323
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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 14
0 NOT ON S
VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) IN B Injury and/or Tow Due To Crash YR 2024I2024-00063491 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 7'1
S STATE ST El ❑
Elgin RELATED ®Y ❑N 10 04 2024 11:55 ❑AM ❑YES ®No u1 -<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W RT20 WB COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW U1
❑ 'WITH VEHICLES INVLD 0 STOPPED U2 —1
® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nmi ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
O 7 / O 3 /1 9 9 7 FOR DAMAGED AREA(S) FRONT TOWED U1
I. mo day yr 13-UNDER CARRIAGE 10 z FIRE ❑ IA <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m
27 RIVER RIDGE DR F SYTM❑Y INS NE
❑UNK VEH. 0 AT CRASH D 0 99-U 15-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN I
THER
j COM VEH 0 r CITY PLATE NO. STATE YEAR POINT OF 8
FIRST CONTACT 12 7_'1 6 • 4 El1 0
-:_.5 ^Y Yes,See Sidebar U1
"2 2Z
MAJ6P1UL8JC221576 State Farm ❑Y ®N U216 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
PEGUERO. DARIO. N. 0133763SFP13 1 m
Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER II 791 HIAWATHA CT. ELGIN . IL.60120 (630)817-7222 VEHU
' ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 by DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
a / / FOR DAMAGED AREA(S) ma-IT TOWED Y N
fi 7 DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C1
c 13-UNDER CARRIAGE 10 j j 2 FIRE ❑ ❑ 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 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'OistractonValue U1 9
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.1I 6 I.
CIO VEH
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 10 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
OPODNR Ut I
(UNIT) (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
1 3 1 0 /25/1992 M 2 8 0 1 0 Shako S. Coleman/1250 AMANDA CIR,ELGIN-IL-60123 Refused r
(224)508-0768 U2 m
/ / #OCCS D
/ / u1 2 m
I I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ISI Y U2 Z
1 ; 1 �� in a Work Zone? DIRP 5 co
43 1 City of Elgin Guard Rail 10,04 /2024 11 55 ®PM ❑N y
PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 C)
T 2 ❑ 150 DEXTER CT ELGIN IL 60120 19 28
! / PM ®Construction *
C 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME0 AM El Maintenance U2
a PM SLMT
ARREST NAME Peguero.Vanessa.j. 11-709-A 752348 / /
o u 1 0 ®CITATIONS ISSUED ❑PENDING ROAD CLEARANCE TIME ` ❑Utility
o N SECTION CITATION NO. AM 20
t 2 0 ARREST NAME Peguero.Vanessa.j. 3-413-F 752349 10/05 /2024 01 00 ®PM 0 Unknown work zone type U1
T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 ®AM Workers present?
1508-Salgado. Leandro 701 10 /28/2024 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
; _r } A CMV is defined as any motor vehicle used to transportproperty and.passengers or D
$ � : 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I ; i combination).or
INDICATE NORTH XI
II : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', i I 0 -t t r r r (example.shuttle or charter bus)-or 0
•, 4 ', I Not To Scale ] t t t - i designed
5 or fewer passengers operated contract rer
transporting employees the course theiremployent(example employee M
i.____A--__: : r i 4 transporter sedor des gnated to rra-usually a van nsport between 9 avehicle or nd
15carpassengers,including the driver,
f I � � � for direct compensation(example.large van used for specific purpose).or O
: : : i ( Rorr�?2oAwrboind I
L_____:____-1 ; 1 emsw? "P film
"P i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example placards will be displayed on the vehicle) XI
CARRIER NAME Z
' ADDRESS 0
N
•
• CITY/STATE/ZIP 0
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
'
r , USDOT NO. ILCC NO.
• , Source of above Z
.
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No PJ
7)
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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
❑ Yes 0 No ❑ Unknown A
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
Form Number 0
m
X1
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
CJ
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
Redcn
U 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons 1 Impound Lot Garage 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