HomeMy WebLinkAbout2024-00069410 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003611453
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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-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2024I 2024-0006941 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n
ST CHARLES ST Elgin 12:18
® ❑ RELATED ' ' 0 N 10 31 2024 12— ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W VILLA ST COUNTY PROPERTY ❑ ® N DOORING® DOORING ❑y #OF MOTOR ID SLOW 15 to
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑De DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FRObir TOWED U1 0NAME(LAST,FIRST,M) Mendiola, Eva,C. mo Chevrolet Astro Van 2000 00-NONE 11 O i"_, DUE TO CRASH 0 13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 3 M
F 2 4 ❑Y ®N
SYSTEM
0 UNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL S I,.4 COM VEH 0 Ea 1 O
F• Elgin I L 60123 0 1 0 FIRST CONTACT 12 7_: _5 *IIYes.See Sidebar IA
Z 9 ET78474 IL 2025
TELEPHONE
IL D 1GBDM19W6YB135202 NONE ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Alonso-Gasca,Adriana,A. NIA 1` r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES ❑NMv 0 NCV ❑DV
/1 9 6 4 Chevrolet Traverse 2023 00-NONE 11 12'"_, DUE TO CRASH ❑ 2
0 Yr 13-UNDER CARRIAGE 10 1 z FIRE ❑ ® U2 C
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
POINT OF s i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 6 I'
FIRST CONTACT 6 Y__{_O -_5 •IfYes.SeeSidebar
= ST CHARLES IL 60175 0 1 0 KSVNTG1 IL 2025 i 0
Z D
IL D 1 G N EVKKWXPJ333886 American Family ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Cicinelli, Mark,A. 41090-55664-90 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 08 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 10/31 /2024 12 18 ®PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 28 99 / / ❑PM• 0 Construction
Z 3 0 I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o 1 ® 11 1 ARREST NAME Mendiola, Eva,C. 11-601 1529-000173 / / El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
8 N ❑AM 30
r 2 ElARREST NAME Mendiola, Eva,C. 3-707 1529-000174 , / ❑pM 0 Unknown work zone type U1
2 2 3 ID OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1529-Audi red,Jonathan 401 275-Engelke 12 /03,2024 09 00 0 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 -<
- }____r__--; _ combination):or
ViIl97St ^ INDICATE NORTH p3
0,1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
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3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
— e transporter-usually a van type vehicle or passenger car):or w
L L-------- 4. Is used or designated to transport between 9 and 15 passengers,including C- } } for direct compensation(example:large van used for specificpurpose):or [he driver,
` Pe ( P 9 Pe or
:. :
L ._i_. � " i i. L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
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L. - CARRIER NAME Z
Not To Scale j 0
i. ADDRESS
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1 CITY/STATE/ZIP �
MOTOR CARR.ID 0 Interstate ❑ Intrastate
. ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; USDOT NO. ILCC NO. m
XI
Source of above z
'
. IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
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 White
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