HomeMy WebLinkAbout2024-00067691 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets 1IH1IlOII III I
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
u, 1 U2 3 4 1 Ui 1 U2 U, 1 U2 U1 1 U2 1 10 U1 11 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$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 S
VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) IN B Injury and/or Tow Due To Crash YR 2024I2024-00067691 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'n
RT20 WB ® ❑
Elgin RELATED ®Y ❑N 10 23 2024 02:31 ❑AM ❑YES ®NO U1
PRIVATE mo /day/yr ®PM FLOW CONDITION m
'COUNTY PROPERTY El Y ®N DOORING ❑Y #OF MOTOR ®SLOW CI)
EP ®/MI 0 E S W Lambert Ln 'WITH VEHICLES INVLD ElSTOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF ) Cook HIT&RUN ElY ® N PEDALCYCUST®N 1=1 FREE FLOW # LNS 0
DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EOUES 0 NIN 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGED AREA(S) FRONTTOWED U1 O
❑EZ.ANAYELY.C. Other Other 2011 00-NONE 0..7z.,0DUE TO CRASH El E
NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE IA
10 z FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 m
1244 SHAWFORD WAY F ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH D 0 99-UNKNOWN THER 9 16-TOP 3 ,DlstractlonValue 9 ALGN I
r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH 0 ® 1 0
FIRST CONTACT 12 7_ ? 6 :_.6 ^Yves,See Sidebar U1
Z
JTLZE4FE1B1139221 Kemper ❑Y ®N U2 19 . m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Olivera. Luis.A. 12AU001142556 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
0 YONDE J N 925 CARRIAGE WAY. Elgin. IL.60120 (224)388-7157 VEHU G1
m ❑DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑RCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 XI
C
c 13-UNDER CARRIAGE 10 I 11 Y FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED C)
A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPCA
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 ^Distraction Value UI 0 -
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61_s C•IOMe68eeSideba❑ 0 C
to
1- r
MAR
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
RESPDYO0N Ut 2
(UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
M
/ / - #OCCS ' D
/ / U1 1 D
/ I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z
N 1 231 1 1 10/23 /2024 02 31 ®pm in a Work Zone? El DIRP co
T 2 ❑
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 1 0
a
/ / 0 PM El Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2
Q ARREST NAME / / ❑PM SLMT
o U 1 0 •0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N 8 AM 45
2 El ARREST NAME / / ptil ❑Unknown work zone type Ut
% T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ ❑AM Workers present? ❑
485-Quintana.Josue 401 - / / El 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
r"0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', ! ' ' 1 ', ' f ` 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
•
CARRIER NAME Z
' .. ADDRESS 0
N
• CITY/STATE/ZIP O
, ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
m
r-----.-----, r r r r r•---, r - DO ILCC NO. m
U N XI
, Source of above Z
. ❑ Yes 0 No ❑ Unknown A
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
CJ
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ 0
U 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Gray
U 3 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑,r DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage 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