HomeMy WebLinkAbout2024-00066525 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III Ifi
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE •
$
El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066525 VENT *
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'I
S RANDALL RD Elgin ❑ RELATED ❑Y coN 10 18 2024 06:10 ®AM ❑YES ®No u1 • ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
231/4 FT/® N E OS W South St COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR 0 SLOW N
Kane HIT&RUN ®Y ❑ N WITH N VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGED AREA(S) FRONT TOWED U, O
NAME(LAST,FIRST,M) , Benjamin mo l day yr J 1 9 9 7 Honda Civic 2018 00-NONE ii O1 , DUE TO CRASH ❑ 21
,3-UNDERCARRIAGE 101 I 2 FIRE ❑ IA E
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 m
SYSTEM IN ENGAGED OTHER 9 16-TOP 3
3N321 SPRINGWOOD LN M
PLATE NO. STATE YEAR POINT OF e l COM VEH 0 ® 4 O
19XFC2F7XJ E011257 State Farm ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
a Montoya, Bejamin. B. 0074246SFP13 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER
o RESPONDER 3 3N321 SPRINGWOOD LN . Elburn. IL.60119 VEHU
0GI
DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 • m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi ' 1 DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
c 13-UNDER CARRIAGE 19) I 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 SPDR 0
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 -
POINT OF •N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II a I_5 C•OM
e63eeSideba❑ 0
C
1- r
TEAR
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 <
RESPONDERlY U, 2
(UNITE I SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)A(TELEPHONE) (EMS) (HOSPITAL) C)
1 3 08 /09/1977 F 2 3 0 1 0 Norma Botello/3N321 SPRINGWOOD LN,Elburn-IL-60119 U2 I—
(630)715-7414 m
/ / #OCCS D
/ / U1 2 m
I I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co
DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 20 1 10/18 /2024 06 10 ❑pM in a Work Zone? ®N DIRP >
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 99 99
! / 0 PM ElConstruction *
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / El PM SLMT
o U 1 0 ' 0 Utility
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8 AM 45
2 0 ARREST NAME / I ptil ❑Unknown work zone type Ut
% T •
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 El
298-Lopez. Mirko 702 - i / 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.
0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
' 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 truckrtrailer -<
' r • ; i ; i- r r , , i combination).or -1
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ' t ` ` ' ' 1f ` r r r (example'.shuttle or charter bus)-or n
S
; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3
transporter-usually a van type vehicle or passenger car).or w
' r i• 4 Is used or designated to transport between 9 and 15 passengers,including the driver,
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
placarding(example placards will be displayed on the vehicle) 11
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP
, ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r ,-•---, r '- DO ILCC NO. m
U N XI
, Source of above Z
. ❑ 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 C
z
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Blue
-
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE