HomeMy WebLinkAbout2024-00071066 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003619339
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-00071066 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED 181 Y 0 N 11 08 2024 ®AM ❑YES ®NO U1 -<
LAWRENCE AVE Elgin07:18
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
FT!MI N E S W N WORTH AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
T
0 4 /
yr
CREIGHTON. DEBRA. K. Jeep(after 19681�rokee 2014 00-NONE 0•
0 �/OUETOCRASH ® ❑
13-UNDER CARRIAGE 16 1 2 FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0THER ga U2 99 171
F 2 4 SYTM❑Y ®SNEDUNK VEH. O ATCRASHD 0 15-99-UUNKNOWN 9 16•TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iL 6 1,.4 COM VEH 0 0 1 0
F. FIRST CONTACT 12 7_:—__,__5 *II Yes.See Sidebar U1
Z CARY IL 60013 B 1 0 BL55069 IL 2025 REAR
TELEPHONE
IL D 0 1 C4PJMCS1 EW192937 STATE FARM ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 1088754SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ❑ N 2 eu
E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 Kcv 0 CIRCLE NUMBER(S) U1
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/1 9 yf 7 Nissan Murano 2006 00-NONE ,�_� t2 -_, DUE TO CRASH p 2
0 13-UNDER CARRIAGE o I 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i�!;_4 COM VEH ❑ ® U1 W
FIRST CONTACT 9 7 _, _5 •• •If Yes.See Sidebar C
ELGIN IL 60123 B 1 0 CD29728 IL 2025 I Si)0
IL D STATE FARM ®Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire RAMIREZ.SILVIA E52839000713A BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused 0 Y°ND
0 N U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 12 / M 2 4 0 1 0
m
/ / #OCCS D
Xl
/ / U1 1 D
/ / 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 4 co
11 ,8/ /024 07 18 ®❑PM AM in a Work Zone? ®N DIRP D
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 ❑ 2 99 / / ❑PM, ❑Construction
4
Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a CREIGHTON. DEBRA. K. 11-904-B 244-1789 / / PM '
—, ARREST NAME ❑
I$!CITATIONS ISSUED 0 TIME ❑Utility SLMT
o u ® 11 4 SECTION CITATION NO. ROAD CLEARANCE AM 30
t 2 El ARREST NAME MOCTEZU MA ZARAZUA. FRANCISCO.J. 3-707 244-1788 , / 0 pM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
244-Blomberg. Michael 601 275-Engelke 11 /26,2024 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
` ` '- ' Not To A - ) 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
71
I INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N - } (example:shuttle or charter bus):or C)
3. Is designed to car 15 otr fewer passengers and operated a contract carrier O
Iiii
-- i 1
} r } transporting employees In the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or C
L •-----}. ...I. �� i i— - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)
LAWR til N for direct compensation(example:large van used for specific purpose):or
l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
_ I _�.: placarding(example:placards will be displayed on the vehicle). ,Zmt
WE
- CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP
'.. I. ' 4 r ir , , „ „ .i.
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --: - USDOT NO. ILCC NO. rn
XI
Source of above z
. 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 M
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
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 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/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE