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HomeMy WebLinkAbout2024-00070540 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII II 0 1I1 EE 11110 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X403615331 u, 1 U21 1 1 2 U, 2 U2 1 U, 1 1_12 1 U1 1 U2 1 5 11 U1 1 U211 *P 0119* 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$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00070540 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 05 2024DAM ❑YES ®NO U1 N MCLEAN BLVD Elgin mo /day/yr 05:22 ®PM FLOW CONDITION m ®2040!MI O E S W Lawrence Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NISLOW 15 u) Kane HIT&RUN ❑V ® 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 ❑EOUES ❑Nuv ❑Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 4 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q Contreras Var as. Hisnaldo.A. 0 9 / yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 4 SY❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 15-OTHER 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I,.4 COM VEH 0 0 1 O ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 • _-5 *If Yes.See Sidebar U1 Z DZ97875 IL 2025 E TELEPHONE IL D 1 NXBR32E05Z402217 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Sirit Contreras,Jesus,J. 981854499 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 17 RESPONDER 2 eu x DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED O PEDAL ❑EWES ❑iiuv 0 NOV ❑Dv '1 9 8 7 Kia Motors Colpportage 2018 00-NONE 11 1 t2 (,-2 DUE TO CRASH ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 6 .t. 4 COM VEH D ® Ut CO FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.SeeSidebar C ELGIN IL 60123 B 1 0 AZ35569 IL 20250 Si)D IL D KNDPM3AC9J7487818 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 975842221 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (IN() (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 u 1 ® 11 1 11 ,51 )024 05 22 ®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 O 2 ❑ 28 03 ( ( ❑PM ❑Construction >E R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Contreras Vargas. Hisnaldo.A. 11-601-Ax 410000674 ( r El PM SLMT S' N • ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 30 t 2 ARREST NAME AM 7 El ( r ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 410-DeLeon,Jessica 601 334-Fries 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 I I ADDITIONAL UNITS FORMS. r ------••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z ` ` -'- -' I '.< ; I INDICATE NORTH combination):Hasfight rating more than 10,000 pounds(example:truck or truck trailer 1. -< BY ARROW 2 Is used or designed to transport more than 15 C ___- ' o sp passengers including the driver 0 I I,-i - } r r r (example:shuttle or charter bus):or I ,;� I 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 -- -_ I I1. transporter-usually a van type vehicle or passenger car):or In C } } 1. transporter •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 0 D I I. t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a placarding(example:placards will be isplayed on the vehicle). m Ni 2> t....n.. CARRIER NAME Z — ADDRESS 0 w n xurasaers CITY/STATElZIP II MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. Not inComm./Other -----Y-- I I USDOT NO. ILCC NO. rTt Xl 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. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Tan Silver 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE