HomeMy WebLinkAbout2024-00068548 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003604215
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2024I 2024-00068548 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I
S RANDALL RD Elgin01:54
® ❑ RELATED ®Y 0 N 10 27 2024 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 Nuv 0!Cu 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 8
FOR DAMAGED AREA(S) FROf4T TOWED U1
Lazaro Qui ano. Manuel 1 2 /
yr
13-UNDER CARRIAGE fal 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 04 M
M 2 8 SYTM❑Y ®S NE EDUNK VEH. 0 AT CRASH 99-UNKNOWN THER9 76•TOP® *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i, B ii,4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 27 :_ L_-_;_-5 *II Yes.See Sidebar U1
Z SOUTH ELGIN IL 60177 B 1 0 EF72550 IL 2025 I
TELEPHONE
IL D 0 2HKRM4H38DH621853 Founders Insurance/Alamo ❑Y Igl N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST.M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Rodriguez. Maria. D. ITIL232273 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
Eg DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 NO! 0 Dv
!1 9 5 5 Ford Edge 2013 00-NONE O-i QrJf i•-0 DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 10( 12 FIRE 0 ® U2 C
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,.4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7�_, .5 •• •If Yes.See Sidebar
n ELGIN IL 60123 B 1 0 P722391 IL 2025 I 0
Z
IL C 0 2FMDK4JC3DBB77251 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Gonzalez. Kathryn. M. 1248145-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 11 / F 2 5 0 1 0
m
/ / #OCCS >
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 10,27 ,2024 01 54 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 06 28 10,27 ,2024 01 54 ®PM El Construction
R 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J 0 AM ❑Maintenance U2
-a, ARREST NAME Lazaro Quijano. Manuel 11-601-Ax S1509000129 10/27/2024 02 02 Igi PM SLMT
oN ® 11 4 •MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
t 2 El ARREST NAME Lazaro Quijano. Manuel 11-902 S1509000128 10/27 /2024 02 22 ®PM 0 Unknown work zone type U1 45
2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1509-Wortman.Cassie 702 11 , 19,2024 01 30 ®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.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} / - r r r (example:shuttle or charter bus):or OC
" ///
3. Is desgned to carry 15 or fewer passen ers and o rated a contract career O
I- I-----A----I _ _ . @ } } i- i- transport) em loyees In the course of their em yment(example:employee X
/ Q transporterg-usually a van type vehicle or passenger car): r
L L.___a__-_� - 1 4. Is used ordesi natedtotrans rt between 9 and 15passengers,includingthedriver. C
} } } for direct compensation(example:large van used for speific purose):or 0
y+v
L L____a____ i i L 5. Is any vehicle used to transport hazardous material(HAZMAT)thatrequires M
s
any
�, �r placarding(example:placards will be displayed on the vehicle).
CARRIER NAME
I- I- -:- '.. )Q/y 7/ ADDRESS0
/ y
V)
r • CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
'LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE