HomeMy WebLinkAbout2024-00067354 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III (III (IIIIII II 111111111111 11111011111 111111111 I
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
El NOT ON S
VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and/or Tow Due To Crash YR 2024I2024-00067354 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 71
N STATE ST ® ❑
Elgin RELATED ®Y ❑N 10 21 2024 08:04 ❑AM ❑YES ®No u1 _<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W WING ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR El SLOW CI)
El 'WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF ) Kane HIT 8 RUN 0 Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0
tg DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EOUES 0 NW ❑NCv ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
0 4 / 2 3 /1 9 8 7 FOR DAMAGEDAREA(S) FRONT TOWED U1 O
,Jose, L. Yamaha YZFR6L 2006 00-NONE 11 12 I 1 DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10)• .r 2 FIRE ❑ 21 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 m
947 N MCLEAN BLVD M ❑Y ESYlM❑UNK VEH. 0 AT CRASHD 0 OTHER
99-UNKNOWN 016-TOP 3 ,Distraction Value 9 ALGN =
CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH 0 ® 1 0
a
JYARJ10E16A001050 None ®Y ❑N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a
99 9 Same None 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
>. RESPONDER Same VEHU73
L ❑Y ®N 2 0
0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
a / / FOR DAMAGED AREA(S) FRONT TOWED
fi 1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE ,t 12 C
c 13-UNDER CARRIAGE 101 I 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 SPOR n
❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value UI 0
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.1I a I_5 CIOMes 3eeSideba0 ❑ C
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m TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF73
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) ISAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
/ / U2
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EV MOST EVNT LOT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
N 1 ® 9 1 10/21 /2024 08 04 ®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 5 C)
T 2 ID 28 99
! I 0 PM El Construction *
c'A 3 0 MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
Q • ARREST NAME Veliz Lizardo,Jose, L. 11-601 485000309 / / ❑PM SLMT
o N1 IE CITATIONS ISSUED El PENDING 0 •SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility 25
2 0 ARREST NAME Veliz Lizardo.Jose, L. 6-101 485000307 10/21 /2024 08 30 ®PM 0 Unknown work zone type U1
T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ®AM Workers present? El
485-Quintana,Josue 501 11 ( 12(2024 09 00 p 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
; _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
D
Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r } i ; 1 INDICATE NORTH combination) or
XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
iNot To Scale 1 -} r r , (example shuttle or charter bus)-or 0
A 3. Is designed to carry15 fewer passegers andoperated by a r
----+-----+ + + I -i } } transportingemployees inof theirx
or a contract Carrie O
5r I } e p oye the course (e mple employeetr 7,
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�____A____: : , 1 3♦ 1 N i i 4a Is usedror designated to trra-usually a van nsport between 9 and 15vehicle or passenger rpassengers,including the driver,
! + + for direct compensation(example:large van used for specific purpose) or O
II
L_____-____; + ® i } , 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
—� / I placarding(example placards will be displayed on the vehicle) Z m l
2.
® CARRIER NAME Z
.. ADDRESS '�
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4Il t 1 cn
• CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0
0 Not in Comm./Govt. Not in Comm./Other
USDOT NO. ILCC NO.
, Source of above Z
). Form Number _ m
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
' TRAILER VIN 1 m
cn
LOCAL USE ONLY TRAILER VIN 2 m
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 ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 1 TOWED BY/TO
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TD E TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO:DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE