HomeMy WebLinkAbout2024-00069899 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY 03�1.4828
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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. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-000MM VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l
® ❑ RELATED ❑Y ®N 11 02 2024 ❑AM ❑YES ®NO U1 -<
N RANDALL RD Elgin06:04
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
1 FT/vt N E S W Royal Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 1 (n
Ill ® O y Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EDUES ❑UU') ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 0
FOR DAMAGED AREA(S) FRONT TOWED U1 Q
Gonzalez Defelipe.Gerardo 1 2 /
yr 13-UNDER CARRIAGE 1a.) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 4 l<Tl
M 2 4 ❑Y ®N SYSTEM VEH. ATCRASHD 99-UNKNOWN 9 7I6�.eTOP 3 `Distraction Value 9 ALGN 2
F F
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRIST NT OONTACT 15 7_il fAII_5 Clfyes.See Sidebar VEH ❑ ) U, 1 0
Z Aurora IL 60505 0 1 0 DA11573 IL 2025 I
TELEPHONE
IL D 0 1 FMJ K1 GT3FEF13416 Progressive ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 977254964 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 row 0 CIRCLE NUMBER(S) U1
Dv
!1 9 6 3 Toyota Corolla 2021 00-NONE ,�_"j 12 -_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 i z FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 9 0
POINT OF S i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 O7 ,�=QI_5 •IfYes.SeeSidebar
Z lake in the hills IL 60156 0 1 0 Z937980 IL 2025 iE 0 N
Z
IL D 0 JTDS4MCE4MJ063064 State Farm ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2057928-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 03 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID
N 1 ® 11 1 11 r 02 l2024 06 04 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 03 28 I / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Gonzalez Defelipe.Gerardo 11-601-Ax W1538000016 r / El PM SLMT
)$I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
8 N 0 AM 50
t 2 El ARREST NAME Niehoff.Steven.J. 11-601-Ax W1538000017 1 r pM 0 Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 50
1538 Estrada. Leticia 900 , / ❑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••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and:
0Z
Not To ScololeJ 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} } ' ',3 ?PA - INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N7RWItlY7Rtl 00. (example:shuttle or charter bus):or
9P, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- <----A----1
- } } } transporting employees in the course of their employment(example:employee �
.•4 I transporter-usually a van type vehicle or passenger car).or co
L L.___a__ + 4. Is used ordesi natedtotrans rtbetween9and15 passengers, ng C} } } g transport pe ific rs, or i [he driver,
I for direct compensation(example:large van used fors specific purpose):or
O
__ ii. L5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
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I i CARRIER NAME Z
ADDRESS 'O
D
w
I ` Royai'+BNd CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other0
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes II 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
White Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 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