HomeMy WebLinkAbout2024-00069698 I LLI NOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111111111111 lilillil R0 iflfl nil i i ii 11 oo111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a610937-
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY N OVER$1,500 El NOT ON SCENE(DESK REPORT) N B Injury and for Tow Due To Crash
El AMENDED
YR 202412024-00069698 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
LARKIN AVE El In05:13
0 ❑ RELATED ®Y ❑N 11 01 2024 ❑AM ❑YES I NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FTlMI N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y N N DOORING ❑y #OF MOTOR ❑SLOW 2 (A
❑ Kane HIT&RUN ❑V N N WITH VEHICLES INVLD ® STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROM TOWED EN
U1 0Avitia.Jose. M. 1 1 /
yr 13-UNDER CARRIAGE 1 •6 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 N U2 4 <<n
M 2 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it 6 4 COM VEH 0 N 1 C)
F. FIRST CONTACT 12 7__,--_,__5 *irYes.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 3311245B IL 2025 REAR
TELEPHONE
IL D 0 3TMCZ5ANXJ M 154868 Ameriancecan Freedom Ins ❑Y Il N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12242413901 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused 0 Y N N 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ o v 0 KCV ❑DV
yr 19) 12 ( E FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3
❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraellon Value 9 U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j( 4 COM VEH 0 N CO
FIRST CONTACT 2 Y'_,--5 •If Yes.See Sidebar
F= 60110 0 1 0 2590703B IL 2025 I0 Si)
IL D 0 1 C6RR7UT9GS272031 Statefarm ❑Y N N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1957556SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 11 101 l2024 05 13 ®AM 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 C)
Er 2 ❑ 25 28 ) / ❑PM ❑Construction *
Z3 0 N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
a ® 11 4 ARREST NAME Avitia.Jose. M. 11-601-Ax S1526000270 / ! 0 PM SLMT
o Nu 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIMEEl AM' ❑Utility
r 2 0 11 1 ARREST NAME 1 1 r 01 12024 06 15 N PM ❑Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1526-Walsh.Jacob 601 11 +26,2024 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 -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
z , - } (example:shuttle or charter bus):or
X
I- I- --I--•--; i i transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener X
} } }
I I � � transporter-usually a van type vehicle or passenger car):or c0
` `-----}----; _ I slz t - • } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
-- for direct compensation(example:large van used for specific purpose):or O
< .I. _ t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
I I r placarding(example:placards will be isplayed on the vehicle). m
I A
; j - I CARRIER NAME Z
ADDRESS 0
V)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes ❑No ❑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 0 0 Z
1-1
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
u 1 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 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