HomeMy WebLinkAbout2024-00067484 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III )III )IIIIII II I 4'�111111111111111110111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
0 NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and JorTow Due To Crash YR 2024I2024-00067484 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
HILLAVE ® ❑
Elgin RELATED ®Y ❑N 10 22 2024 02:39 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W ADDISON ST 'COUNTY PROPERTY ❑Y ®N COOKING ❑Y #OF MOTOR ❑SLOW 1 U)
❑ WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NMV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 3 / 0 3 /2 0 0 4 FOR DAMAGED AREA(S) FRONT TOWED U1
, Monica. M. Ford Fusion 2018 00-NONE 0' ..'�..D DUE TOCRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE 0
IA
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 El U2 0 m
469 ADDISON ST F SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASH 99-UUNKNOWN 9 16-TOP 3 Distraction Value 9 ALGN =
THER
r CITY PLATE NO. STATE YEAR POINT OF 8 . :_.5 ^
FIRST CONTACT 12 7_71 6- 4 COM VEH 0 El1 0
Y Yes,See Sidebar U1
Z
3FA6POLU1JR206536 State Farm ❑Y ❑N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
Same 1706288 SFP 13 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 G1
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FROM TOWED
, NAME(LAST,FIRST,M) Valencia Soto. Reydavid 0 9 1 mo day yr 6 2 0 0 6 Infiniti Q50 2015 00-NONE 11: 12 1 REocRasH O 0 U2 273
v 13-UNDER CARRIAGE o .?_Z C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® SPDR C
SYSTEM IN ENGAGED 0 15-OTHER 9 TOP 3 9 0 X
a` 213 NATIONAL ST M ❑Y MI N DUNK VEH. AT CRASH 99-UNKNOWN 6 Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 9 7_Il a 1_5 C•IOMe6 3eeSidebaH ❑ ® U1 to
~ ELGIN IL 60120 0 CM86681 IL 2025 REAR 0 CCn
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(331)645-4258 V452-7200-6264 IL D 0 JN1 BV7AR8FM391192 KEMPER ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I
Valencia. Reynaldo 12AU001481682 BAC 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
213 NATIONAL ST. ELGIN . IL.60120 (331)588-1851 U1 =
(UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)){ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
I I - U2 996 r
m
- #OCCS y
/ / U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z
N 1 ® 1 1 4 10,22 /2024 02 39 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 3 ..
2 0 2 23 10,22 /2024 02 39 ®PM ❑Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
0 AM ❑Maintenance U2
Q ARREST NAME Torres Ramos, Monica. M. 11-1204-B 1538-005 10/22/2024 02 42 ®PM SLMT
1 ❑ 11 1 ' ❑Utility
p UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME
0 ❑ SECTION CITATION NO.
o N AM 30
I 2 ® 31 3 ARREST NAME 10/22 /2024 03 10 El RA0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? El Y 30
1538-Estrada, Leticia 301 334-Fries 11 , 12/2024 01 30 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
; _� } 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
` ` 1 ; ' ' I 141111? 0 r r INDICATE NORTH combination) or XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
` i I ', i Ifit -l• ` r r r (example.shuttle or charter bus)-or 0
designedcarryor fe passengersand operatedr 0
<____a____. 4 i I _t } t transporting eelinthecoursoftheirem ent( ample�emaployeerie M
�� dnf f tr nsppoorter-usually a van type vehicle or passenger car).or 03
_____:_____: : i , ^� '4r i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N
4 for direct compensation(example:large van used for specific purpose).or
0
11
L_____L____; ; , i , 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires rn
iplacarding(example placards will be displayed on the vehicle) 71
' CARRIER NAME
' I .. ADDRESS '�
ITo
. Not To Scale j n
CITY/STATE/ZIP
I l. MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. El Not in Comm./Other
r , USDOT NO. ILCC NO.
, Source of above Z
. 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 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
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 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. 2
White Black
-
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 2 TOWED i. .1
DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO Arties VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE