HomeMy WebLinkAbout2024-00067457 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III (IIIIII II I r
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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 SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and/or Tow Due To Crash YR 2024I2024-00067457 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT
VARSITY DR ® ❑
Elgin RELATED ®Y ❑N l O 22 2024 11.39 ®AM ❑YES ®No U1 .<
PRIVATE mo /day/yr El PM FLOW CONDITION m
Egli �/
COUNTY PROPERTY El ®N DOORING 0 Y #OF MOTOR ElSLOW U1
MI O E S W Maroon
) Cook HIT&RUN ❑Y CZN WITH PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EODES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
O 9 / O 6 J 2 O O 6 FOR DAMAGEDAREA(S) FRONT TOWED Ut
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mo day yr
,3-UNDER CARRIAGE 101 2 FIRE ❑ IA <
SEX SAFT AIR AUTOMATION LEVEL LEVEL D 0 (1�-TOTAL(ALL) DISTRACTED 0 1 U2 m
1166 PEGWOOD DR M ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,DistractlonValue 9 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8 I{ 6 II COM VEH 0 ® 1 0
A ~
WAUR4AF58JA104040 State Farm ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
ONTIVEROS-HERNANDEZ.TERESA,T. 1753405-SFP-13 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r
L RESPONDER 1166 PEGWOOD DR. ELGIN . IL.60120 (224)325-0721 VEHU G1
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0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH CIRCLE NUMBER(S) U1
MAKE MODEL YEAR 2 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi , DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE ,t 12 73
a 13-UNDER CARRIAGE 10 I Ij 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR 1
A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN e 4 'Distraction Value UI 4
N CITY —
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STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 7_11 8I_8 SidebarEH
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID V1N 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) (GOB) ISEXI (SAFT) (AIR) {INJ( (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)r!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 0 Y U2 Z
1 1 43 2 Cityof Elgin Tree 10,22 ,2024 11 39 ❑pti, in a Work Zone? Ill N DIRP co
PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM If YES check one below: U1 1 C)
T 2 0 150 DEXTER CT ELGIN IL 60120 32 28
! r 0 PM El Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
a ARREST NAME / / ElPM SLMT
o U 1 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N 8 30
2 0 ARREST NAME r / AMM p ElU1
Unknown work zone type
N T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 0 ❑AM Workers present? 0
1504 Real. Hilario 302 272-Bajak i , ❑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
; ; , A CMV is defined as any motor vehicle used to transport passengers or property and.
�=
Gg_ 01 Hasa weight rating more than 10,000 pounds(example truck or truck/trailer
combination)or
r ', ', .� t r / ® r INDICATE NORTHXI
• BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I
` } J. J. ', i / l' ` r r r (example.shuttle or charter bus)-or
i
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_----....---�
/t f ) } } } transporting employees in the course of their employment(example employee
transporter-usually a van type vehicle or passenger car).or w
�____A____: .t / i r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose).or O
`- '-- --' ; ' , Maroon?D r. } } } 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
O` J placarding(example placards will be displayed on the vehicle) 71
�' I L CARRIER NAME
' .. ADDRESS D
' �� / CITY/STATE/ZIP
/ Not To Scale . • MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. El Not in Comm./Other
r , /
USDOT NO. ILCC NO. m
, Source of above Z
. ❑ Yes ❑ No ❑ Unknown g
Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID
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
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
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 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. rn
Gray
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE EDTO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BYITO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE