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HomeMy WebLinkAbout2024-00071295 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 II 0 III I Mil 1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40361D260 u, 1 U21 2 1 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 5 15 U1 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2024I 2024-00071295 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 11 09 2024 ®AM El YES ®NO U1 N ALDI N E ST Elgin01:44 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 5 / yr 13-UNDER CARRIAGE 10 ! 2 FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 F 2 5 0 0 2 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 11 Y COM VEH 0 0 1 C) ~ ELGIN I L 60123 B 1 0 FIRST CONTACT 6 tz,:LQ_0 •II Yes.See Sidebar U1 0 Z ED57535 IL 2024 REAR TELEPHONE IL D 7 19UUA8F24CA020242 American Family ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Alonso.Griselda. N. 2318-8955-05 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 N v 0 DV !1 9 9 9 Mazda CX9 2012 00-NONE 0.. Q!'-O DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE 10 I f: 2 FIRE ❑ ® U2 C F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-il 6 I1:, 4 COM VEH ❑ ® U1 W FIRST CONTACT 12 7� .6 •(ryes.See Sidebar H ELGIN IL 60123 0 1 0 DC21003 IL 2024 I 0 C IL D 0 JM3TB3CAXC0343570 Allstate Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Ledesma. Rosa. L. 811-305-571 BAC $ 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) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 11 ,91 ,024 01 44 ®❑PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n T 5' 2 ❑ 2 28 1 , ❑PM, ❑Construction * 4 Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Samaniego.Yetzy.A. 11-901-A 1510-000488 / r El PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 30 r 2 0 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1510-Cortes. Reyna 601 11 ,26,2024 09 00 ❑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 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` -' -' r INDICATE NORTH combination):or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ I1. - } r (example:shuttle or charter bus):or L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.__-a-_- 4. Is used or designated to transport between 9 and 15 passengers,including the driver, KII } for direct compensation(example:large van used for specific purpose):or I I t I 1:-. } };III L--_-a-___. L i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m rn placarding(example:placards will be displayed on the vehicle). N_7Aldino7St.-1...‘ I I I I© w ep.7Cnlc wat - 1 -r 1i CARRIER NAME Z _ ADDRESST. 0 In CITY/STATE/ZIP g I - i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other I I I --, , I USDOT NO. ILCC NO. m xi Source of above z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ No 0 Unknown M D Did Carrier Safety Regulations(MCS)violation contribute to the crash? A ❑ Yes I 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 ❑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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Gray 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE