HomeMy WebLinkAbout2024-00068458 (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 2
0 NOT ON
VEHICLE/PROPERTY ElOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00068458 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
GEORGE ST ❑Elgin RELATED ❑Y coN 10 27 2024 00_20 ®AM ❑YES ®NO U1 ,-<
PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y M N DOORING ❑Y #OF MOTOR ID SLOW U1
❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS 0
❑DRIVER X PARKED ❑DRIVERLESS ❑ PEE 0 PEDAL ❑EOUES 0 NW 0 Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1
Nissan Sentra 2017 00-NONE 11 I 12 y,DUE TO CRASH El - E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( ll
®' 2 FIRE ❑ ll <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
SYSTEM IN O ENGAGED 0 15-OTHER ®9 '6-TOP 3 0 ® _
/ El INN DUNK VEH. AT CRASH 99-UNKNOWN 6 4 COM VEH ❑ ® 1 n
'Distraction Value ALGN
r POINT OF CITY PLATE NO. STATE YEAR j �
FIRST CONTACT I, O O (6'�" 5 'If Yes,See Sidebar U1 0
Z ZZ72342 IL 2025 REAR
. ID VIN INSURANCE CO. EXPIRED
3N1AB7AP6HL652951 Unknown El ❑N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Y 99 9 Palencia Turrubiates, Paulina Unknown 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER E N 262 G EO RG E ST. Elgin, I L.60120 (630)546-2627 VEHU 6)
m ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PEE 0 PEOAL ❑EQUES 0 NUN ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi 1 DUE TO CRASH ❑ El —I
, NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 C
c 13-UNDER CARRIAGE 10 j I 2 FIRE ❑ ❑ U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0a
❑Y ❑N El ow AT CRASH 99-UNKNOWN 8 4 'Distraction Value U1 0 -
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 61-5 CIO MVSee Sidebar❑
REAR 0 C
Ca
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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 <
RESPONDER
YOQ NR Ut =
(UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
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I I #OCCS D
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/ I U1 >
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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 1 ® 11 1 10/27 /2024 00 20 ❑PM in a Work Zone? El DIRP D
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 I
5 0
a
T 2 ❑
! / 0 PM ❑Construction >F
N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM ❑Maintenance U2
Q 1 Cl ARREST NAME Espinoza, Edwin, R. 11-601-Ax 1512422 / / El PM SLMT
o U ®CITATIONS •ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
N AM 25
2 El ARREST NAME Espinoza. Edwin. R. 11-601-Ax 1512423 r / 8 ptil ❑Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 0
❑AM Workers present? ❑Y
1512-Juarez-Huichapan,Juan 400 11 r 12/2024 01 30 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.
^ 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, . r r r r , , , , . r .
Z
1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer
✓ 'I 1 ; i i i f i- r r , , i INDICATE NORTH combination)or —I
X
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` I ', ! i. ` ' ' 1 ', ' l' ` r r r (example.shuttle or charter bus)-or 0
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----i-----a a a I t • : - -, I I + i } - t transporting employees in the course of their employment(example.employee 71
transporter-usually a van type vehicle or passenger car).or 03
' i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver
r 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) M
•
CARRIER NAME Z
' .. ADDRESS
N
' CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate ❑ Intrastate <
• . ❑ Not in Comm./Govt. ElNot in Comm./Other 0
r---- ----, , , r r r r r----, , , , r USDOT NO ILCC NO. m
, Source of above z
#) Li Side of Truck Li Papers Li Driver H Log Book m
Z
GVWR/GCWR —I
❑ <10,000 0 10,000-26,000 1=1 >26,000 z
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard 0
4 digit UN NO. 1 digit Hazard class No X
X
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicles 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% p
❑ 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
z
Form Number CJ
_ m
— X
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2
TRAILER VIN 1 _ m
to
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >10? m
TRAILER 1 ❑ ❑ ❑ z
71
TRAILER 2 ❑ ❑ ❑ 3
u 3 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't z
Gray
U 3 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY!1
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE