HomeMy WebLinkAbout2024-00068658 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets HUI III 0 )fall
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
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YR 2O24I 2024-00068658 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
BALTUSROL DR El in07:39
® ❑ RELATED ®Y 0 N 10 28 2024 ®AM ❑YES El NO U1
_ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ARONOMINK N K CIR COUNTY PROPERTY ❑Y El N DOORING Ely #OF MOTOR El SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O n
FOR DAMAGEDAREA(S) FRO fir TOWED U1 O
NAME(LAST,FIRST,M) Alvarado.Amelia mo8 / /1 9 9 1 Honda Odyssey 2019 00-NONE 11 OI_, DUE TOCRASH ElEN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
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STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m
F 2 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 976•TOP 3 ,Distraction Value 5 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 4 COM VEH ❑ El 1 0
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TELEPHONE
IL D 0 SFNRL6H56KB021845 Liberty Mutual ❑Y J N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same AOS24826664170 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
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❑YNi N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton value 0
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
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;UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 02 /
LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El
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N 1 El 11 1 10/28 l2024 07 39 ®❑PM in a Work Zone? NJ DIRP >
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1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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F.; 2 ❑ 2 41 / ! ❑PM ❑Construction *
Z 3 ❑ I!II CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Alvarado.Amelia 11-901-A S1507000327 / / ❑PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM U1 30
r 2 ❑ ARREST NAME 10/28 /2024 08 13 I PM ❑Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1507-Ruiz.Alondra 702 275-Engelke 12 / 10/2024 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 —I
A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ Li - } , (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
I- <.__-A-.-.� N transporting employees in the course of thir employment(example:employee
Not To Scale transporter-usually a van type vehicle or passenger car):or CO
L L.___a.._..I. - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
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1 } } } for direct compensation(example:large van used for speific purose):or 0
L L--_-a-...i i NNW* - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
U,Ytt placarding(example:placards will be displayed on the vehicle). :t1
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�Unit 2 CARRIER NAME Z
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CICITY/STATE/ZIPT.
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MOTOR CARR.ID ❑ Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 USDOT NO. ILCC NO. m
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Source of above z
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Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
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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
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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
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Form Number 0
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IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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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
White White
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 DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE