HomeMy WebLinkAbout2024-00042566 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003607:00'
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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. TUN/Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
®AMENDED ❑ B Injury and f or Tow Due To Crash YR 202412024-00042566 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 1 :l
FULTON ST El In 10:00
® ❑ 'RELATED ❑N 05 07 2024 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo 1 day r yr ❑PM FLOW CONDITION m
FT!MI N E S W S CHAPEL ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 U.)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FROM TOWED U1 Q
FOR DAMAGEDAREA(S) FRO
Saenz.Saul 1 0 /
yr 13-UNDER CARRIAGE IE
101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 00 M
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 ALGN =
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL a 4 COM VEH 0 j$J 1 O
m H SOUTH ELGIN N I L 601 77 0 1 FIRST CONTACT 12 7_; __5 *rives.See Sidebar Di
Z DH79196 IL 2024 E
TELEPHONE
IL D 0 3B4GE17YOMMO05622 None ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
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Same None 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ® N 2 0
m Ei{ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 row 0 KCV 0 DV
9 9 0 Nissan Altima 2017 oo-NONE 1("i 12 `, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10'I 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
POINT OF 8 .i. 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR � a I'"
FIRST CONTACT 6 l:!�:�"O,zf�S •IfYes.See Sidebar
PINGREE GROVEZ IL 60140 0 1 0 P665734 ILaR C
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IL A 7 1 N4AL3AP3HC266234 American Family Insurance ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 9 =
Aguilera. Melissa 410223247251 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SART) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 07,09 r2024 05 55 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
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2 0 28 99 r r 0 PM• ❑Construction *
1
Z 3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
oEl 11 1 ARREST NAME Saenz.Saul 11-601—Ax 399003436 r r El PM SLMT
o N i!i CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
❑AM 30
t 2 0 ARREST NAME Saenz,Saul 3-707 399003437 r r ❑pM ElUnknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
399-Kazy-Garey. Daniel 301 - r r ❑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
Not To Scale41111 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
`----------' I r INDICATE NORTH �mb natbn)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
_ X
VS 3. Is designed tocarry15 fewer passengers and operated a contract carrier O
eS or
. . . transporting employees in the course of their employment(example:employee I X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l VC
•I. 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
` C for direct co nsatio (example:I van used for cr M rt
t F > 9 a pros NO
11
L L_ � rrajas) o t i. i i. _ 5. Is any vehicle used to transport sport any hazardous material(HAZMAT)e)tha requires
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__ _ _ placarding(example:placards will be displayed on the vehicle).
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CARRIER NAME Z
ADDRESS 0
T.
, V)
I- I- -I- -I 1 11 r
CITY/STATE/ZIP C)
_ MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
--- --1 USDOT NO. ILCC NO. m
73
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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' 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE