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HomeMy WebLinkAbout2024-00067540 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II 010 �1 1IIIIII 11111111 1111 11111 III 101111 fill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2273 u, 1 U2 1 1 1 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 5 12 U1 1 U2 1 *P 0119* 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 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067540 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m CENTER ST El ❑ Elgin RELATED ❑Y coN 10 22 2024 07:09 ❑AM ❑YES ®NO U1 ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m ®1 OQ/MI N E O W East ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EouEs ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 / 2 9 /2 0 0 7 FOR DAMAGEDAREA(S) FRONT TOWED U1 , D. Mercedes-Bert232 AMG 2020 00-NONE �� 12 , DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( 2 FIRE ❑ 1M 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 53 U2 m 417 PRAIRIE ST M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6 !1 6 It COM VEH 0 ® 1 0 W1 K3G4FB9W225269 BRISTOL WEST ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Garcia De Amaro, Rosa Maria G01-2606697-03 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'I" OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L RESPONDER E 417 PRAIRIE ST, Elgin, I L, 60120 (224)580-5025 VEHU G1 2®DRIVER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDALL ❑EQUES ❑NUN ❑NCV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) AMBROCIO ALVARADO,SILAS, I. 0 mo6 d /y2 0 2 0 0 0 yr Nissan Altima 2018 00-NONE 11: 1$ ' '1 DUE TO CRASH ❑ ® 2Xi v 13-UNDER CARRIAGE t j 2 FIRE ❑ El U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 IN SPDR n SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 X 2014 BERKSHIRE CIR M ❑Y ® N ElUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 0 N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIR I8T NT COONTACT 2 7. .I 6 •• •.5 C•OM VEH See Sidebar IN U1 to I.. C 60110 0 AZ71768 IL 2025 REAk0 (/j M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)960-8067 A516-7890-0175 IL D 0 1N4AL3AP2JC473252 UNITED EQUITABLE INS ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same PPT6003214 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YOND N Same Ut = (UNIT' (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) I I - U2 996 1- m - '#OCCS > 73 / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 11 1 10,22 /2024 07 00 0 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 1 C) T 2 0 20 50 ! / 0 PM El Construction * N 1 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM Maintenance U2 1 El• ❑ Q ® 11 1 ARREST NAME Amaro. Emilio, D. 11-708 51519-000203 / / El PM SLMT o U ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility N AM 30 2 0 ARREST NAME Amaro, Emilio, D. 6-101 S1 51 9-00 0 20 2 r / 8 ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 1519-Bae2a.Guadalupe 301 - r / Q PM Am Workers present? ®N U2 30 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 . 4 } AMV is defined as any motor vehicle used to transport passengers or property and. Z 1 CH as a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or —I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i ', i t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 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 desi nated to trans rt between 9 and 15 assen ers 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 T. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, i r - DO ILCC NO. m U N XI , Source of above Z . —I Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 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 ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Black Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE