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HomeMy WebLinkAbout2024-00071488 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II OUI 00110000000 I lID DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003619201 u, 1 U21 3 4 8 U, 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00071488 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ❑Y ®N 11 10 2024 ®AM ❑YES ®NO U1 190 RAMP Elgin 07:59 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT l MI N E S W DUNDEE DEE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Ramos. Reynaldo 0 5 / yr 13-UNDER CARRIAGE ©10,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 4 ❑Y ®SNEM D15-OTHER UNK VEH. 0 AT CRASHIND 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 j$J 1 0 ELGIN IL 60120 0 1 0 FIRST CONTACT 11 7_; __5 *II Yes.See Sidebar U1 ZEG56490 IL 2024 REAR TELEPHONE IL D 0 JH4CU26699C033680 BRISTOL WEST ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 1 99 9 Same G01305783902 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 9 2 c m E{ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑MAV 0 N CIRCLE NUMBER(S) U1 v ❑Dv $ /1 9 8 8 Lexus GX460 2022 00-NONE 'o,� t2 (,-2 FIRE DUE ocRASH ® U2 2 C o - 13-UNDER CARRIAGE ID c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 3 POINT OF 8 1 iI 4 COM VEH D El U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �J 5 FIRST CONTACT 5 7 _,SOS F.(ryes,See Sidebar Z CHICAGO IL 60657 0 1 0 4835CC IL 2025REAR C Z IL D 0 JTJAM7BXXN5322986 AMICA ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X 1 99 9 SMITH. ROBERT.V. 95051220QH 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)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 m ##OCCS > / / / / U1 1 D / / 1 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 11 ,10 /2024 07 59 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 ❑ 28 11 / / ❑PM, ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Ramos. Reynaldo 11-601 374001284 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility t 2 ❑ ARREST NAME AM 7 / / pM El Unknown work zone type 30 U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 374-Rizzu-o. Michael 201 275-Engelke 12 /03/2024 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 owoFauvewue T 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer combination):or -< r__--. ( —INot To Scale_i INDICATE NORTH 71 II BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier O - ------I----; I y I . I- . transportingemployees in the course of their employment pbyment(example:employee 73 Fev+oFFarAnv transporter-usually a van type vehicle or passenger car):or C L L.__-a-_- ` % - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, y for direct compensation(example:large van used for specific purpose):or L L--_-a i I-___� 1 ' L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m e placarding(example:placards will be displayed on the vehicle). XI —UNIT -- —1 CARRIER NAME Z I 4. ADDRESS O I I i CITY/STATE/ZIP g \ 0 _ MOTOR CARR.ID El ElIntrastate 1 r I I ❑ Not in Comm./Govt.. Not in Comm./Other USDOT NO. ILCC NO. C XI Source of above z xi 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? ❑ Yes II No 0 Unknown A 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 VIM 1 m LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO: SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE