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HomeMy WebLinkAbout2024-00071150 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100IR1111I11DDVVI000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003619313 u, 9 U2 1 1 1 u, 2 U2 1 U1 99 1_12 U,99 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00071150 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m 2480 N RANDALL RD Elgin03:18 ® ❑ RELATED ❑Y ®N 11 08 2024 DAM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ''Y ❑N DOORING ❑y #OF MOTOR El SLOW 1 (n ❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0 Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOR 3 M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction value ALGN = $ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I�6 '• COM 1 0 1— FIRST 9 FIRST CONTACT 99 7 ;I -5 *If Yes.See&debar U1 2 Z ' E TELEPHONE IL Other NIA ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same NIA 1 I- `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r D Y°®N 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/v 0 NOV 0 DV yr Toyota Camry 2024 013-NONE 10' t2 (,-2 FIRE DUE o CRASH 0 ® U2 2 73 C o _ 13-UNDER CARRIAGE Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 0 ® SPDR 0 ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istrac Dn Value 9 U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR j 6 i' COM VEH ❑ ® CO H EQ75451 I L FIRST CONTACT 5 7 OS •(ryesREAR- ,See Sidebar Z U2 0 M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 0 4T1 R11 BKORU131312 State Farm ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Benitez. Natalie 2421678SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 11 ,08 /2024 03 18 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 30 99 N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! ❑PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 z -a, ARREST NAME / / El PM o u El 1 • 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 15 r 2 ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 Y 15 1506-Nunez. Maria 901 - / / 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 -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 ® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or X i.___A..-. Not To Scale 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 — transporter-usually a van type vehicle or passenger car):or w C L L.___a__._. - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, I — 1�� } } } • for direct compensation(example:large van used for speific purose):or L L--_-a-.... — la�� - i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D — e placarding(example:placards will be displayed on the vehicle). ,Zmt —1 — CARRIER NAME Z t° i�0 M ADDRESS 0 CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --• - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations I/ICS)violation contribute to the crash? A ❑ Yes No ❑ 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'; 0 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 Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE