HomeMy WebLinkAbout2024-00065382 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
01101100 M 011110 fit 11011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003585698
u, 1 U2 1 1 1 U1 5 U2 1 U, 1 1_12 1 U+ 1 U2 1 5 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00065382 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
367 NORTH ST El 11:29
® ❑ RELATED ❑Y ®N 10 12 2024 12— ❑YES ®NO U+ -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
0 3 /
yr
Chevrolet Traverse 2024 00-NONE + DUE TO CRASH ❑ 01
++- +2 -
13-UNDER CARRIAGE 10 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m
F 2 SYTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED 0 99-UNKNOWNU 9 +6_TOP 3 ,Distraction Value 1 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 4 7 . __5 *II Yes.See Sidebar U1
Z EJ79591 IL 2025 E
TELEPHONE
IL D 0 1 G N ERG KSO RJ 152457 State Farm ❑Y Il N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Vlllegaz Carreno. Biviano 3134986SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 KKv 0 DV CIRCLE NUMBER(S) U1
yr 13-UNDER CARRIAGE 10 1 12 2 FIRE 0 ® U2 C
c ij SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 +6.TOP 3 1 0
a ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 6 )�', 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® CO
F, FIRST CONTACT 11 Y �_ _5 •Irves.See Sidecar C
Q164579 IL 2023 RFJ 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2HKYF18514H572789 Kemper Insurance ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
GERARDO.CELIA 12AU001469725 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (0OB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (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 ® 18 1 10,12 i2024 11 29 ®PM AM in a Work Zone? ®N DIRP D
co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 06 06 + 1 0 PM 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Villegas. Monica.C. 11-801-A 15110000296 r r El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
0 AM
t 2 0 ARREST NAME 10/12 12024 11 29 ®PM 0 Unknown work zone type U1 25
n -r OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 25
1511-Ayala. Roberto 300 , ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , 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 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zt
--I
CARRIER NAME Z
ADDRESS 0
co
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
73
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
Black Silver
u 1 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE