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HomeMy WebLinkAbout2024-00068600 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV u, 1 U2 1 1 1 U1 1 U2 U, 1 1_12 U+ 1 U2 5 12 U1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00068600 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 10 27 2024 ❑AM ❑YES ®NO U+ VILLA ST Elgin mo /day/yr 06:27 ®PM FLOW CONDITION m 010 ®!MI N OE S W SADLER Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW (/) Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW/ 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) Honda Accord 2012 00-NONE FOR DAMAGEDAREA(S) mom TOWED U1 0 t NAME(LAST,FIRST.M) Valtierra Camacho.OSWaldo. D. mo /0 3 / yr © DUE TO CRASH ® ❑ + 12 13-UNDER CARRIAGE O 9 I .! 2 FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 m M 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a �i 4 COM VEH 0 Ea 1 O " �- LAKE I N THE HILLS I L 60156 0 1 0 FIRST CONTACT 11 7 : -s *II Yes.See Sidebar U1 ZEW45989 IL 2025 TELEPHONE IL D 0 1 HGCP2F34CA031936 State Farm ®Y 0 N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Cortez.Stephany K677941D1613 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 ou 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 - C o 13-UNDER CARRIAGE t�.i :., FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR O ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-S C•IO e1sVEH See •Sidebar❑ 0 C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m / 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 10,27 /2024 06 27 ®AM in a Work Zone? NJN o1RP co T I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) 0, t 2 0 ! / ❑PM• El Construction Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM ' o u 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME El t 2 El ARREST NAME 1 0!27 12024 07 31 ®PM El Unknown work zone type U1 30 CO 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 1507-Ruiz.Alondra 302 334-Fries 11 , 12,2024 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. 0 A CMV is defined as for vehxae used to tra and: r ----,5-••--, ; any mo nsport passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - } }-- -;-- --; } } } r -, , ; ; , ; ( combination):or —I INDICATE NORTH 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or x 3. Is L L.___A_. 1 i. <--_- - J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , < .---_-a-___� , J. , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.I L L L ...._-..i._ 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z i. ADDRESS 0 fh CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m 73 Source of above z ) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m Z GVWR/GCWR 1 El <10,000 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. P3 XI Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 73 IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 3 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue U 3 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE