HomeMy WebLinkAbout2024-00069469 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100
111 ff11111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003607701
u, 1 U21 1 1 1 u, 8 U2 1 u, 1 1_12 1 u, 1 U2 1 1 11 u,25 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El5501-S1,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00069469 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1
® ❑ RELATED PRIVATE ❑Y ®N 10 31 2024 ❑AM YES ®NO U1 -<
ST CHARLES ST Elgin mo /day/yr 04:43 ®PM FLOW CONDITION M
20�C7/MI N E O W Hammond Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 Cl)
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
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EDUCE ❑NIA/ 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
r'!l�@1I�
FOR DAMAGEDAREA(S) MOM TOWED U1 Q
NAME(LAST,FIRST,M) Morales Pena.Yosimar.Y. mo /2 0 0 0 General Moto 2007 00-NONE ,, DUE TO CRASH ® ❑
13-UNDER CARRIAGE 12! FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0 U2 4 <<Tl
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 76•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a �i 4 COM VEH 0 0 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 1 7_;- -_5 *IIYes.See Sidebar U1
Z EF55574 IL 2025
TELEPHONE
IL D 0 1 G KFK163X7J 178521 Statefarm ❑Y Il N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2337649-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Ialy 0 i v 0 Dv
/1 9 6 2 Kia Motors Cooporte 2021 00-NONE ,�_"j t2 -_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 i z FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..is-TOP3 X
❑Y ON DUNK VEH. AT CRASH 99-UNKNOWN *Oistraetlon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'1 6 .t. 4 COM VEH 0 ® Ut CO
I� FIRST CONTACT 6 O7 �_ =Q)OS •If Yes.See Sidebar
KINGSTON IL 60145 0 1 0 AV45840 IL 2025aR g
So
IL 0 3KPF34AD0ME264052 Statefarm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 8 x
Same K327441-CO1-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 / M 9 4 0 1 0
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,31 /2024 04 43 ®pm 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 .r
o"
2 0 20 99 / / ❑PM ❑Construction
R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME Morales Pena.Yosimar.Y. 11-709-A 474000553 , / El PM SLMT
o N
-
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
r 2 ❑ ARREST NAME AM
7 , / pM El Unknown work zone type 30
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
474-Jacobs.Tyler 401 334-Fries 12 /03,2024 09 00 ❑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
// EAN)
ADDITIONAL UNITS FORMS.
r ----r••--, , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I / /
01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
i- }-- •-I-- --' j U INDICATE NORTH combination):or
ii
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
ff - (example:shuttle or charter bus):or 0
J Unit 2 r r r 3. Is designed to carry15 or fewer I Ig passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
Itransporter-usually a van type vehicle or passenger car):or w
L L____a____� I •} } } 4. Is used or designated to transport between 9 and 1passengers,includingthedriver,
C
for direct compensation(example:large van used fors specific purose):or O
L L____a____.I Unit t _ t i. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
I _ _ ADDRESS 0
D
St?Charles?St l ut
I I CITY/STATE 2IP O
C)
1 ` - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I I 1 ❑ Not in Comm./Govt. Not in Comm./Other
0
Y USDOT NO. ILCC NO. mVo!71,Scale I
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spit 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
co
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
Silver Orange
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Owners Residence . 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