HomeMy WebLinkAbout2024-00067721 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III )III IIII lull
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11 III II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602231
u, 1 U21 3 4 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500El NOT ON S®ON SCENE 14
VEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067721 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 7'1
HIAWATHA DR El ❑
Elgin RELATED ®Y ❑N 10 23 2024 04:45 ❑AM ®
❑YES NO u1 -‹
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W SUMMIT ST 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U)
❑ Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
tg DRIVER 0 PARKED 0 DRNERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NMV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
FOR DAMAGEDAREA(S) FRO
, Maria.G. 1 2 / 1 5 J 1 9 8 1 M TOWED U1
1999
NAME(LAST,FIRST,M) mo day yr Lincoln Navigator 00-NONE 13-UNDER CARRIAGE 11 I 12 I Y 0DUFIREE TO CRASH ® ❑
) ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® U2 00
10 m
270 CENTER ST 1 F ❑Y ESYlM❑UNK VEH. 0 AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN =
CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii-4 COM VEH 0 ® 1 0
a
5LMPU28A6XLJ33052 FALCON ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a Same 0100123349-5 1
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ❑N 2 G�
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / J FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Perez.Yoselin m0 10 0 d9ay
2 0 0 4 Toyota Prius 2013 00-NONE ;o) 12 D FIRE TO CRASH O 0 U2 2 C
v 13-UNDER CARRIAGE
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 1)
a` 4011 BURTON TRL F
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X
❑Y El DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR I8T CNT OONTACT 1 TF _II 6 I_5 CIOMeb$eeSideba❑ Igl U1 to
• C
Z PEAR Crystal lake IL 60014 C DL35250 IL 2025 0 fp
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)875-8608 P620-9600-4609 IL D 0 JTDKN3DU0D0345060 State Farm ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I
GOMEZ. CONCEPSION 04390434910-SFP-13 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
0N 4011 BURTON TRL.Crystal lake. IL.60014 (224)875-9602 U1 =
(UNIT) I SEAT) (DOBi (SEX, (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL)
2 3 10 /1 4/2004 M 2 5 B 1 0 Marcos Lopez/743 HIAWATHA DR.ELGIN,IL,60120 Elgin Fire Refused 996
(847)220 1350 _ g U2 m
/ / #OCCS D
/ / • u1 1 m
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z
N ® 11 1 1 D,23 /2024 04 45 ®pm in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AMU1 1
2 0 25 2 10,23 /2024 04 46 ®PM El Construction *
N 3 0 izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
® 11 •
1 ARREST NAME Ramirez. Maria.G. 11-902 1546000003 10/23/2024 04 49 Ili PM SLMT
o U CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME < 0 Utility
o N SECTION CITATION NO. AM 30
2 0 ARREST NAME 1 0i 23 /2024 05 19 EllPM 0 Unknown work zone type Ut
T •
• OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1546-Ignacio. Patricia 201 - 11 ,26/2024 01 30 ®PM 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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
AD
DITIONAL UNITS FORMS
; _� } A CMV is defined as any motor vehicle used to transport passengers or property and.
0D
j 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer -<
_Not To Scale t combination) or —I
r INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
J. ', i ®i ! i r r r (example'.shuttle or charter bus)-or 0
0
3 Is designed to carry 15 or fewer passengers and operated carrier
i
----?-----. -r } } t transporting emplo ees in the course of their em ment(example�emaployeerie
Y ploY
Imrra i J 1 ~ ` transporter-usually a van type vehicle or passenger car).or w
C
i.____A____: : , i : r 14 Is used or designated to transport between 9 and 15 passengers,including the driver,
_____ for direct compensation(example.large van used for specific purpose).or O
L_____'____1 ;1 i , i n. i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
J 4' placarding(example placards will be displayed on the vehicle) n
2.
CARRIER NAME Z
' .. ADDRESS 0
To
CITY/STATE/ZIP
. MOTOR CARR ID ❑ Interstate ❑ Intrastate
j •
• ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
" • •
• USDOT NO. ILCC NO.
m
XI
, Source of above Z
.
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No PJ
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
2
Form Number 0
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 m
to
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. Z
Green Silver
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage 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