HomeMy WebLinkAbout2024-00066980 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 8 Sheets 1111111 010 III )III 11111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E417
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON S
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00066980 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I
RIVER BLUFF RD Elgin ❑ RELATED ❑" co" 10 20 2024 01:48 ®AM ❑YES ®NO u1 ,<
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
'COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR ❑SLOW N
El /MI N E S W Cook HIT&RUN ❑Y ® " WITH N VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
I&DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
0 4 / 0 4 /2 0 0 1 FOR DAMAGED AREA(S) FRONT TOWED U,
Buick LeSabre 2000 00-NONE O I O 0 DUE TO CRASH El ❑NAME(LAST,FIRST,M) RODRIGUE,VANESA mo day yr
,3-UNDERCARRIAGE i z FIRE El ® <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ❑ ® U2 m
10N835 S MAPLE ST F SYM
❑Y ®SNE❑UNK VEH. O AT CRASHD 0 99-UNKNOWN O9 16-TOP 3 ,Distraction Value 9 ALGN 2
IN
CITY PLATE NO. STATE YEAR POINT OF 8 i 6 1 i+ 4 COM VEH 0 El 1 O
F FIRST CONTACT 12 7_ :{_�5 ^Yves,See Sidebar U1 0
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Same nla 1
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r
'' RESPONDER VEHU
• Same
L ❑Y ®" 2 0
m ❑DRIVER ❑ PARKED 0 DRNERLESS 0 PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 ON DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi 7 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C1
c 13-UNDER CARRIAGE 101 I 2 FIRE ❑ 0 U2 C
i STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ❑ SPDR C)
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •DistractionValue U1 2
POINT OFto
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_1I a I_5 CIO VEH
0 C
H R • C
0.2
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 995 <
D YOEl N Ut I
(UNIT) ISEATI (DOB) (SEX) (SAFI) (AIR) I INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)f(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) n
1 3 / / 9 5 0 9 9 Unknown/ U2 m
I / - - #OCCS y
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/ / U1 2 m
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 5 PEREZ, EDGAR, I. front retaining wall 10,20 ,2024 01 48 (23 PM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1
2 ❑ 150 RIVER BLUFF RD ELGIN IL 60120 08 28
! / PM ❑Construction *
c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q • ARREST NAME DE LATORRE RODRIGUE.VAN ESA 11-502.15- 752374 / / El PM SLMT
o U 1 0 ®CITATIONS ISSUED ❑PENDING ROAD CLEARANCE TIME 0 Utility
o N SECTION CITATION NO. AM 25
2 ❑ ARREST NAME DE LATORRE RODRIGUE,VAN ESA 11-601-Ax 751631 10/20 /2024 02 20 ®PM 0 Unknown work zone type U1
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-- 0
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 El A" Workers present?
1 535-Solis. Laura 102 11 , 17,2024 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
; _r } 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 ', ', r INDICATE NORTH
l.
combination) or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver XI
J. I d i -` ` r r r (example.shuttle or charter bus)-or 0
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i.-----;------i 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
i_____-:----_: : i , I y1 ..ram I -i i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u)
for direct compensation(example:large van used for specific purpose).or O
, , 6 . , 1.1
L____-____-; ; ; , - i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
' placarding(example placards will be isplayed on the vehicle) XI
M
I.
- — — — —
CARRIER NAME Z
I ♦ En
t ADDRESS 0n
. . ii
I •
CITY/STATE/ZIP
r ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r ,
USDOT NO. ILCC NO.
• , Source of above Z
_ GVVVR/GCWR
❑ <10,000 0 10,000-26,000 0 >26,000 Z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No PJ
7/
m
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 A
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
Form Number 0
m
73
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
CJ
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
GoldEn
U 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑Lr DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
Arties/Impound Lot Garage 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