HomeMy WebLinkAbout2024-00064535 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003581378
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2024I 2024-00064535 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 71
KI M BALL ST El04:22
® ❑ RELATED ®Y ❑N 10 09 2024 12,— ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION RIFT/MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 0)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
C)
FOR DAMAGEDAREA(S) FROM• TOWED U1 0Fernandez. Felix. D. 0 7 /
yr 13-UNDER CARRIAGE 1U • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 O r11
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s. i�B 4 COM VEH 0 El 1 0
F. FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar U1
Z Carpentersville IL 60110 0 1 0 3705703E IL 2025 REAR
TELEPHONE
IL D 0 1 FTYR14UX8PA77358 American Alliance ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILAA085932201 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused El El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 Dv
/1 9 yr7 8 Mazda CX9 2007 00-NONE O, ' Qj O DUE TO CRASH 0 2
0 13-UNDER CARRIAGE I FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il��:- 4 COM VEH ❑ ® U1 CO
H
FIRST CONTACT 12 Y _, .5 •(ryes,See Sidebar
ELGIN0
M IL 60120 0 1 0 AH45275 IL 2025
IL D 0 JM3TB38Y370112831 Statefarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire Gaitan.Amalia 0718225SFP13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
1 1 0 6 / M 2 3 B 1 0
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/ / #OCCS >
71
/ / UI 2 D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 10,09 l2024 04 22 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 25 99 10,09 /2024 04 34 El PM ❑Construction >E
R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM 0 Maintenance U2
a1 ® 11 4 ARREST NAME Fernandez. Felix. D. 11-306 1500000280 10,09/2024 04 43 ®pM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
0 AM
t 2 El ARREST NAME 10/09 /2024 05 09 ®PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1500-Chew. Marie 102 334-Fries 11 , 18/2024 09 00 ❑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 truckrtrailer -<
i- }-----I-----; 0 I - I. combination),or
INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
- } (example:shuttle or charter bus):or
Not To Scale I 1 urns I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
- ------I-----� I i. } } } transportingemployees in the course of their employment
pbyment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l _ jp-' 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
C
} } for direct compensation(examp large van used for speific purose):or 0
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
-I
CARRIER NAME Z
ItM"°s°'°r I ADDRESST.r V)
0
CITY/STATE/ZIP
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE