HomeMy WebLinkAbout2024-00066217 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III HI IIII lull
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03539561
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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
[23 NOT ON SVEHICLE/PROPERTY El OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2O24-00066217 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71
S RANDALL RD ® ❑
Elgin RELATED ❑Y coN 1 O 16 2024 02:54 ❑AM ❑YES ®No u1 .(
PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 U1
❑ FT/MI NESW 'WITH VEHICLES INVLD CISTOPPED U2 —1
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT 8 RUN ❑Y IM N PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑ECUES 0 NW ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1
. Unknown Unknown Unknown Do-NONE 11 12 i' , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE 0 IASTREET SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 O m
UNKNOWN UNKNOWN F SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 =
❑Y ❑N DUNK VEH. AT CRASH ®-UNKNOWN Distraction Value ALGN
V. CITY PLATE NO. STATE YEAR POINT OF & {I�j 4 COM VEH 0 El 1 O
F FIRST CONTACT 6 7__._ 5 'If Yes,See Sidebar U1 0
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UNKNOWN Unknown ❑Y ❑N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a Unknown. Unknown Unknown 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER
>. RESPONDER UNKNOWN . Unknown. Unknown VEHU
L ❑Y ®N 99 0
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 WV ❑soy 0 oV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m
m 5 / / FOR DAMAGED AREA(S) FRONT TOWED Y N
NAME(LAST,FIRST,M) Cruz. Nelly. E_ 0 mo day 1 9 yr7 Toyota Toyota Corolla 2017 oo-NONE
13-UNDER CARRIAGE '0I 12 Y FIREETocRasH ❑❑ ® U2 2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n
E 621 DOUGLAS AVE F
SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 9 X
❑Y ® El UNK VEH. AT CRASH 99-UNKNOWN Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT g T_II a I_5 C•IOMe6 3eeSidebaH ❑ ® U1 to
H ELGIN IL 60120 0 CJ77208 IL 2024 I 0 CCI)
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(956)483-5311 C620-6257-6747 IL D 0 SYFBURHE6HP709258 Geico ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Cruz.Jorge-A. 6037879092 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER 0N 621 DOUGLAS AVE. ELGIN . IL.60120 (956)560-0754 Ut =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)1(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 i ® 11 5 10/16 /2024 05 30 0 pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C)
T 2 0 18 18
! / ❑PM ❑Construction *
c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7
Q 1 CO 11 5 ARREST NAME / / El PM ❑Utility SLMT
0 U CI CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8AM 10
2 0 ARREST NAME 1 / ppl ❑Unknown work zone type Ut
T OFFICER ID SIGNATURE BEAT/DIST. •
SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 10
537-Sanders. Richard 702 334-Fries 1 / ❑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
; _� Q} A CMV is defined as any motor vehicle used to transport passengers or property and.
D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r 1 i i combination) or —I
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L , f NWmSCOr I ® -I' . r r r (example.shuttle or charter bus)-or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
t-----;-----% 4 i -i } - i transporting employees in the course of their employment(example.employee M
transporter-usually a van type vehicle or passenger car).or w
' ii _: i r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver,
C
for direct compensation(example large van used for specific purpose).or O
__ ; ; , i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
-13
placarding(example placards will be displayed on the vehicle) 71
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Ww +..wrw ` _ T.
CARRIER NAME Z
' t ADDRESS 0
N
CITY/STATE/ZIP C.)
r ,
MOTOR CARR ID ❑ Interstate El Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r , ^ USDOT NO. ILCC NO.
, Source of above Z
. If Yes Name on placard 0
4 digit UN NO. 1 digit Hazard class No M
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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 0
C
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ -
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number D
m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
D
TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z
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Silver
-
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE