HomeMy WebLinkAbout2024-00070454 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
IIIIII 01011111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO0 613612
u, 1 U21 1 1 2 U1 2 U2 1 U, 1 1_12 1 U1 1 U2 1 1 11 U1 11 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2024I 2024-00070454 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 m
® ❑ RELATED ❑'F ®N 11 05 2024 ®AM ❑YES ®
PRIVATE NO U1
N RANDALL RD Elgin mo /day/yr 09:35 ❑PM FLOW CONDITION m
•
®2040!MI 0 E S W Fletcher Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 3 v)
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
ti DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
_ 0 2 /
yr 13-UNDER CARRIAGE 1a.) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 ❑Y ®N SYSTEM
❑UNK VEH. AT CRASH 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T :il a 4 COM VEH 0 Ea 2 C)
F. FIRST CONTACT 12 _ __5 *Irves.See Sidebar U1
Z ST CHARLES IL 60174-2560 B 1 0 483908D IL 2025 I _,
TELEPHONE
IL D 1 FTSX20569EA80528 Elite Insurance Solutions ❑v ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
MBR Mobile Truck Rep 5256656400 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV CIRCLE NUMBER(S) U1
1 9 9 3 Ford Transit Connect 2023 00-NONE 11_-1 12..-_, DUETO CRASH rg ❑ 2
oyr 13-UNDERCARRIAGE 10,1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
POINT OF s 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 �'
FIRST CONTACT 6 Q �.0:-_OS •(ryes.See Sidebar
Aurora IL 60504 B 1 0 M241614 IL 2024 tzF aR 0 N
IL D NMOLS7S26P1565966 Underwriters at Lloyd's L ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
City of Carbondale PK1031023 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
m
##occs y
/ U1 1 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 11 ,51 ,024 09 35 ®❑pM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 0 03 28 , , ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Espinoza Lopez.Julian 11-601-Ax 410000673 r r ❑PM SLMT
S' N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 El45
ARREST NAMEAM
7 ❑❑pM El work zone type U1
/ r
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
410-DeLeon.Jessica 602 275-Engelke 12 , 17,2024 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.
. 0
r ----r••--, , J - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; I ( 1. Hasatlonighr more thanpounds(example:truckortruckrtrarler 1. Hasa rating10,000 -<
INDICATE NORTH A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
Ii- - (example:shuttle or charter bus):or
1 3. Is designed to carry15 or fewer 0` A g passengers and operated a contract career 0
} } } transporting employees In the course of their employment(example:employee P3
transporter-usuallya van vehicle or type passenger car):or co
-- - I. } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
•for direct compensation(example:large van used for specific purpose):or o
L �____a____� � } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
• - CARRIER NAME Z
N ADDRESS 'n
w
4.
CITY/STATE/ZIP
— —
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other O
Not To Scale_f CC NO O
, _Y_ I I I USDOT NO. IL m
XI
Source of above z
—I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. 71
73
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations MCS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Redmons/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 Redmons/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE