HomeMy WebLinkAbout2024-00067713 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III HI IIII lull
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602232*
u, 1 U2 1 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 15 U1 1 U2 1 *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 •
1
0 NOT ON SVEHICLE/PROPERTY En OVER$1.500 0 AMENDEDCENE(DESK REPORT) IN B Injury and JorTow Due To Crash YR 2024I2024-00067713 VENT *
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'I'I
S LIBERTY ST El ❑
Elgin RELATED ®Y ❑N 10 23 2024 03:51 DAM ❑YES ®No u1 ,‹
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W MAY ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR El 1 U)
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL ❑EOUES 0 NMV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0
0 9 / 0 9 /1 9 8 4 FOR DAMAGEDAREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) , ELLEN, M. mo day yr Acura MDX 2018 00-NONE 1112 , DUE TO CRASH ❑
DI
13-UNDERCARRIAGE FIRE 0 IA
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 EI U2 1 n<7
651 NOR OAKS CT F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3O,Distraction Value ALGN =
CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH 0 El 2 O
a ~
5J8YD4H37JL017554 NONE ❑Y ❑N U2TIT m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a Same NONE 1 I—
t HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 17
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m
m FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Y N
s BARRAZA ROGRIGUEZ, MARIA 0 4 / 0 1 /1 9 8 1 Toyota Camry 2021 00-NONE Xi
13-UNDER CARRIAGE O' AN,11 Dt DUE TOCRASH (ffi 0 FIRE El [2] U2 2
v mo day yr
c 10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 C
DISTRACTED 0 IN SPOR C)
a 1129 TH ELI N CT F
SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X
❑Y El DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF
FIRST CNT ONTACT 12 7_'1 a 1_5 C•IOMe6VSee Sidebar ® U1
to
H Batavia IL 60510 0 25653PT IL 2025 REAR 0
Sn
2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(331)300-4787 B626-5588-1694 IL D 0 4T1G11AK4MU479793 KEMPER ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 12AU001571876 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
Y NR Same U1 =
(UNIT) (SEAT) (DOB) (SEX) (SART) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
I I - uz 996 1-
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z
N ® 11 1 10,23 /2024 03 50 0 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 7
2 0 2 23 10/23 /2024 03 51 ®PM ❑Construction *
N 3 ❑ ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
Q 1 CO 11 1 ARREST NAME NELSON, ELLEN, M. 3-707-A-5 S1519-000204 10/23/2024 03 55 ®PM SLMT
o U ®CITATIONS ISSUED El PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME < 0 Utility
rn AM 30
I 2 0 ARREST NAME NELSON. ELLEN. M. 11-1204-B S1519-000204 10/23 /2024 04 20 El RA0 Unknown work zone type Ut
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. •
SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1519-Bae2 a.Guadalupe 401 - 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
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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
' •_ ', ', ! (- t- ._ ' ' '. ', ' 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------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 Hated to trans rt between 9 and 15 assen ers including the dr ver,
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
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placarding(example placards will be displayed on the vehicle) .Z1
I.
. `
CARRIER NAME Z
' ADDRESS 0
N
• CITY/STATE/ZIP n
, ,
. - MOTOR CARR ID ❑ Interstate ElIntrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
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r-----.-----, r r r r r•---, r - DO ILCC NO. m
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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 P3
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 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z
En
Beige Red
-
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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE