HomeMy WebLinkAbout2024-00069747 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003610929
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-00069747 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
VILLA ST El In 09:47
® ❑ RELATED ®Y 0 N 11 01 2024 12,— ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
FT!MI N E S W NATIONAL ST COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (/)❑ Kane HIT ❑V ® N WITH VEHICLES INVLD El STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 WIN 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROhir�TOWED U1 Q
NAME(LAST,FIRST,M) RODRIGUEZ.JOCELINA m0 D 3 / /1 9 9 9 Nissan Rogue 2013 00-NONE „_, Qi�DUE TOCRASH ® ❑
13-UNDER CARRIAGE ) FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 ]$I U2 2 (T1
SYSTEM IN ENGAGED 15-OTHER
M 2 40 0 9 16•T 3 _
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 it®COM VEH 0 E! 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 2 7_; __5 *IIYes.See Sidebar Ut
Z EV21012 IL 2024 REAR
TELEPHONE
IL D 0 JN8AS5MT6DW542744 AMIGOS INSURANCE ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same PPQ6004259 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
/1 9 8 9 Chevrolet Malibu 2015 00-NONE O, Qj'O DUE TO CRASH ❑ 2
J. _ 13-UNDER CARRIAGE I 1 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,IS-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
POINT OF s i1 C 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7. �I�.S *(ryes,See Sidebar
= Hanover Park IL 60133 0 1 0 AT16815 IL 2024 I 9
IL D 0 1 G11 DSSLXFF192121 PROGRESSIVE ISI Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 975899013 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 6 06 /
2 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 ,01 /2024 09 47 ®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)
v 2 ❑ 2 15 11,O1 /2024 09 48 ®PM ❑Construction >E
<w O o xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 4
3 ❑AM 0 Maintenance U2
—a, ARREST NAME RODRIGUEZ.JOCELINA 11-902 1516-000466 11/01 /2024 09 51 Igi PM CITATIONS ISSUED PENDING SLAT 1 ® 11 1 ❑ • Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 y
El AM
r 2 0 ARREST NAME 1 1/01 /2024 10 20 0 PM 0 Unknown work zone type U1 30
2 2 3 ID El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1516-Mancera. Maria 401 11 , 19/2024 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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH comWrtation)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
3. Is desgned to car 15 or fewer ssen ers and o rated a contract career O
- } } } transporting employees In the course�of their empbym�ent(example:employee � �
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - I. } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, 0
for direct compensation(example:large van used for specific purpose):or o
L L___-a..... `--L L _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 1 1 1 0 placarding(example:placards will be displayed on the vehicle).
CARRIER NAME
Z
1 ADDRESS 'n
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1 CITY/STATEYZIP g
r C
Not To Scel. MOTOR CARR.ID 0 Interstate ❑ Intrastate O
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- '-1 USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 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 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
Red 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE