HomeMy WebLinkAbout2024-00067536 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ 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) ® B Injury and/or Tow Due To Crash YR 2024I2024-00067536 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I
W CHICAGO ST ®gin ID
❑Y coN 10 22 2024 06:39 ❑AM El ®No u1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
yN'000/MI N E S® RIVERSIDE
) PEDALCYCUST® ® FREE FLOW # LNS 0
Ig DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
.Julissa,A. 0 3 / 1 1 J 1 9 9 7 Toyota Camry FOR DAMAGEDAREA(S) FRONT TOWED Ut
2022 00-NONE 11 12 i' 1 DUE TO CRASH ❑ 21
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10( .r 2 FIRE 0 ICI <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) • DISTRACTED 0 ISI U2 m
1122 BIRCH DR 3 F ❑Y ISYNM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF & {IaNj 4 COMVEH 0 ® 1 0
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4T1K61AK9NU004573 STATE FARM ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 SANTILLAN. LIANKA K688614D2313 1
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o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >
'' RESPONDER 1131 ASH DR 2, ELG I N . I L.60120 VEHU
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❑DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEOPL ❑COVES 0 NUN ❑Ncv 0 ov DATE OF BIRTH CIRCLE NUMBER(S) U1
MAKE MODEL YEAR m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi 1 DUE TO CRASH 0 ❑ —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 XI
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c 13-UNDER CARRIAGE 10 I .I 3 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 ❑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 CIOMe63eeSideba❑ ❑ C
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M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
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❑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) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z
N 1 ® 11 1 10,22 /2024 07 01 0 pm in a Work Zone? ®N DIRP co
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PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 3 C)
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! / PM El Construction *
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME / / El PM SLMT
o U 1 ❑ 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N B AM 30
2 ❑ ARREST NAME , / pti1 ❑Unknown work zone type Ut
2 3 ❑ • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ElY
1506-Nunez. Maria nu334-Fries 11 , 12/2024 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.
r 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. Z
r- -r--- 4 , 4 r r r r r , , , 1 . r
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
' r •• ; i ; i- r r , , i r r INDICATE NORTH combination) or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
' •_ ', ', ! i. ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or
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3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------t-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M
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
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CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP O
, ,
• . - MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
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, Source of above Z
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Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No
73
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% A
❑ Yes No ❑ Unknown 0
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
X1
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 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
BlackEn
-
U 3 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