HomeMy WebLinkAbout2024-00065603 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets Millill I 01101100 M 0
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00358.0 3
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INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00065603 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mSHULER ST Elgin
® ❑ RELATED ❑Y ®N 10 13 2024 ❑AM ❑YES ®
PRIVATE NO U1
mo /day/yr 08:56 ®PM FLOW CONDITION ITT
00 0/MI NOS S W South Union St COUNTY PROPERTY El'COUNTY ® N DOORING Elv #OF MOTOR ❑SLOW 2 rA
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
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) mo
Unknown.0. Unknown Unknown 00-NONE EN E
13-UNDER CARRIAGE ,, • 12 DUE TOCRASH ❑
yr ) ! FIRE 0 CR
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 DISTRACTED ❑ 0 U2 2 MM 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,i�6 �i,_ 1 0
~ 0 9 0 FIRST CONTACT 2 7_; _5 *IIYes.See Sidebar Ut
REAR
2 Z ' E
TELEPHONE
UNK. Other Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 0
E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑N4v 0 NCv ❑DV
/2 O 0 4 Chevrolet Silverado 2014 00-NONE 11 12 _, DUE TO CRASH ❑ 2 73
o r _ 13-UNDERCARRIAGE FIRE ID El U2
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF 8 ) 4 C.OM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 10 Y ��r-b *IfYes,See Sidebar C
H Burlington IL 60178 0 1 0 3395303B IL 2025 I 0 t;p
IL D 0 3GCUKREC7EG424281 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Gonzalez Mendoza. Riboberto 1603977SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 4 02 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,13 /2024 08 56 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 18
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + / _ ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
—a, ARREST NAME / / ID PM '
o u ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2 ARREST NAME AM
7 1 / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 30
492 Gardrer. Mikaela 601 334-Fries , / ❑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 truck trailer -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L L.___A.._.� s.�u:o�a 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O
i �� } } } transporting employees in the course of their employment(example:employee X
L • __I.,.. ...I. I - I. } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and 15rC
passen passengers,including the dryer,
�1 for direct compensation(example:large van used for specific purpose):or 0
L [- - I
... — -- _ =„ t l. I. 1 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
u
placarding(example:placards will be displayed on the vehicle). m
;0
• CARRIER NAME Z
Not To Sce/e ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --• - USDOT NO. ILCC NO. m
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 M
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE