HomeMy WebLinkAbout2024-00069421 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003637 0r
u, 9 u21 2 4 9 U199 U2 U199 U2 1 U,99 U2 1 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00069421 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
KATHLEEN DR Elgin
® ❑ RELATED ❑Y ®N 10 31 2024 DAM ❑YES ®
PRIVATE NO U1
mo /day/yr 01:35 ®PM FLOW CONDITION m
•
OO 1C.'J!MI N E O W MULBERRY Ln COUNTY PROPERTY ElY 21 N DOORING ❑Y #OF MOTOR IR SLOW 1 rA
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
18:DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 8
FOR DAMAGEDAREA(S) FRO r TOWED U1
NAME(LAST,FIRST,M) Unknown.O. mo / , yr Unknown Unknown 00-NONE 11;. O I_1 DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL a �i,4 COM VEH 0 j$J 1
~ 0 9 0 FIRST CONTACT 12 Y i mai -5 *If Yes.See Sidebar Ut 0
2 Z ' E
TELEPHONE
IL Other UNKNOWN ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UNKNOWN 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr .I 1y -1 DUE TO CRASH ❑ ® 1 ,'�
13-UNDER CARRIAGE 10;1 !. 2 FIRE 0 El U2 C
Ti
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �`il COM VEH 0 ® U1 W
F,,, FIRST CONTACT 6 Q:: �_.OS •If Yes.See Sidebar
CZ44013 IL izF aR 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 N4AL11 E35C384878 UNIQUE INSURANCE ❑Y 123 N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
99 9 Guerrero.Alma. D. ILP2509930 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 10,31 /2024 01 35 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 28 99
N 3 0 0 CITATIONS ISSUED 0 PENDING 1 1 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
z
-a, ARREST NAME / / El PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
r 2 ARREST NAME AM
7 1 / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
1506-Nunez. Maria 602 334-Fries 1 / ❑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
/J I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' -' r INDICATE NORTH combination):or —I
® BYARROW 2 Is used orttlrchtotran transport C
designed
sp passengers including the driver C
r r r (example:shuttle or charter bus):or
` ` -A--- ; MULBERRY7LN�, - . - . transporti3. Is ng employened to es the course ofth or fewer eir eers mplod yment example:employeerier 73
Not To Scale transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - } } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or O
L L____a____. o _ L L L i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
a
placarding
(example:placards will be displayed on the vehicle). XI
—I
CARRIER NAME Z
_ ADDRESS D
P.O.1.
y rn
z CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rTt
XI
Source of above Z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 Yes 0 No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE