HomeMy WebLinkAbout2024-00066198 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III IIII lull
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003539570*
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
1
0 NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash yR 202412024-00066198 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
FOX LN ® ❑
Elgin RELATED ❑Y coN 10 16 2024 04:47 ❑AM ❑YES ®No u1 ,•<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
®1 0RD1 MI O E S W HOLM ES Rd COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW N
Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
tg ORNER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EOUES 0 NW 0 Nee 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
0 5 / 0 2 /1 9 8 7 FOR DAMAGED AREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) , Rosalva mo day yr Honda Accord 2009 00-NONE QiO /1 DUE TO CRASH ® ❑
13-UNDER CARRIAGE z FIRE ❑ ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL (ICI TOTAL(ALL) ® O DISTRACTED 0 1l U2 m
1325 WING PARK BLVD F ❑Y IN NSYSTEM DUNK VEH. 0 ATCRASH D 0 99-UUTHER NKNOWN 9 6 TOPO •Distraction Value 9 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF N I I O COM VEH 0 ® 1 n
1 HGCS12899A023818 American Freedom ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Same 12243600700 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r
'' RESPONDER Same VEHU
L ❑Y ®N 2 G1
0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑ECUED 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
ra / / FOR DAMAGED AREA(S) FRONT TOWED
fi i DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 C
a 13-UNDER CARRIAGE 10 I 11 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPOR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value UI 0
POINT OFto
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT �_II a I_s CIO MVSeeSidebar
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
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❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
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(UNIT) (SEAT) (DOB) (SEX) ;SAFT( (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z
N ❑ 1 3 10,16 /2024 04 47 ®pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5
2 ® 43 3 10 99 10 16 2024 04 47
CO
( I ®PM ❑Construction *
N , 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
ARREST NAME Cobon Martinez. Rosalva 6-101-A 1506-281 10/16/2024 04 50 ®PM SLMT
o U 1 CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME ❑Utility
SECTION CITATION NO.
N AM 30
2 ❑ ARREST NAME 10/16 /2024 05 20 ®PM 0 Unknown work zone type U1
2 •3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1506-Nunez, Maria 502 334-Fries 11 , 12/2024 09 00 0 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
; •01 _, } A CMV is defined as any motor vehicle used to transport passengers or property and.
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1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r } 1 i i ‘NN\
; ; combination) or
INDICATE NORTH �1
t ; t \ Not.TO Scale l' L r rBYARROW (example shuttle designed
r charter bus)--or�re than 1 passengers including drover C Is 5 en ers in the
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pdesignedcarryfewer passengersoperated by a r
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Ist c 15ora a contract car
<____a____. , , •O� \ _. } } transporting in thecou ofth rempl0 nt(ex mple�emaployeerie 0
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i_____A____: : , i i 4a suosedrordesgnatedto rra-usually a van nsportbetween9andvehicle or 15carpassengers,indudingthe driver,Jam. for direct compensation(example.large van used for specific purpose).or O
L____-� ____ ; j � , i } iany
5 Is any vehicle used to transport hazardous material(HAZMAT)that requires m
placarding(example placards will be displayed on the vehicle) 71
: L : LCARRIERME
' LL / .. ADDRESS 0
To
1 ,
CITY/STATE/ZIP
HDLMI°S?RD itMOTOR CARR ID ❑ Interstate ElIntrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
USDOT NO. ILCC NO. m
, Source of above Z
. own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown g
Did Carrier Safety Regulations(MCS)violation contribute to the crash? O
❑ Yes No ❑ Unknown 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 5
2
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
White
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_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO.
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE