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HomeMy WebLinkAbout2024-00062901 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIII lull 1111111111111111111111111111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O3532508 u, 1 U21 1 1 1 U1 1 U2 1 U, 1 U2 1 Ut 1 U2 1 1 14 Ut 1 U2 1 *P 0119* 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-$1.500 ®ON SCENE • 7 0 NOT ON S VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 20241 2 024-0 0 0 62901 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 11 MAROON DR ®gin El ❑Y coN 10 02 2024 07'32 ®AM ❑YES ®No u1 • ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ®SLOW 1 U) ❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® 0 FREE FLOW # LNS ' 0 tg oRNER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 1 0 / 0 4 /2 0 0 7 FOR DAMAGED AREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) mo day yr ,Tobias. D. Nissan Altima 2013 00-NONE 11 0Q DUE TO CRASH 0 13-UNDERCARRIAGE 10 2 FIRE 0 1l < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m 1250 SPRING CREEK RD M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF . • COM VEH 0 El 1 00 F FIRST CONTACT 12 7_.; 6-:_.5 ^Yves,See Sidebar U1 Z State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Robbins, Nicole 0601707sfp13 1 o HOSPITAL(TAKEN TO) INCIDENT IF"Y" OWNER STREET CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 1250 SPRING CREEK RD. ELGIN . 11_60120 (224)290-4592 VEHU > ®cRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m 4 /m FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) Murillo,Stephanie 0 mo day d y9 2 0 0 3 Ford Focus 2011 DO-NONE 13-UNDER CARRIAGE O:' 1'_+ DUE TO CRASH ❑ ® Xi ( 2 v ©'. 2 FIRE El El U2 c 10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) C DISTRACTED 0 ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 a` 692 CHIPPEWA DR F ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN II •DistractionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 11 7_'1 9 1_5 G•IOMeeVSee Sidebar ® U1 H ELGIN IL 60120 0 Y916026 IL 2024 I 0 CC11 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)800-6036 M640-7800-3722 IL D State Farm ❑Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Murillo_Joaquin 0849400sfp13 BAC ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 690 CHIPPEWA DR. ELGIN . IL.60120 (224)800-6036 U1 = (UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME),(ADDRESS)/;TELEPHONEI (EMS) (HOSPITAL) n I / U2 996 r m / - '#OCCS D / /• U1 1 D I I 1 0 EV MOST EVNT LOC_DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 1 1 10,02 ,2024 07 35 ❑pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 3 0 T 2 0 14 11 ❑AM ! / 0 PM El Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance uz ® 11 1 ARREST NAME / / El PM 0 Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 00 T 2 0 ARREST NAME r / ppl ❑Unknown work zone type Ut a OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME El Y 00 339-Sterricker, Beth 393-Gutierrez , / ❑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. , r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . 0 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z "--r----, , 4 r r r r r , , , , . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r i ; i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! t- t ' ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------'-----• + + • : - 1 1 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi Hated to trans rt between 9 and 15 assen ers including the dr ver, 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. CARRIER NAME Z ' t ADDRESS 0 D f/1 • • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other Q C r-----.-----, r r r r r•---, r - DO ILCC NO. m U N XI , Source of above Z _ GVVVR/GCWR ❑ <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 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 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Brown Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TOWED ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO 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 VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE