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HomeMy WebLinkAbout2024-00071064 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II I 1001110 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03621232 u, 1 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U1 4 U2 1 .P0119* 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 ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202412024-00071064 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m ® ❑ RELATED ®Y 0 N 11 08 2024 ®AM ❑YES ®NO U1 BIG TIMBER RD Elgin06:48 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W N RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0 0 7 ! yr 12 - 13-UNDER CARRIAGE 1U 2 FIRE El NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 5 <<T1 M 2 SY n is-OTHER 4 ❑Y ®SNE❑UNK VEH. AT CRASIN n H 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S T,_iL S 4 COM VEH 0 j$J 1 0 F. FIRST CONTACT 00 ;—, _5 *b yes.See Sidebar U1 Z Crystal Lake IL 60014 0 1 0 487186D IL 2025 TELEPHONE IL D 1 FT8W3DT3BEB77803 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 1 99 9 JR and Sons Construe 956420978 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 24 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑!My 0 NCv ❑DV yr Mazda CX5 2016', Do-NONE 0 ©z i.0 DUE TO CRASH rg ❑ 2 73 o - 13-UNDER CARRIAGE 10 I I.. 2 FIRE ❑ ® U2 C c M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 POINT OF i 0 s 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S �S COM VEH_ C FIRST CONTACT 1 7 _, _5 •(ryes.See Si ❑ ® U1 IN debar PINGREE GROVE Z IL 60140 0 1 0 X486696 IL 2025 REAR 0 Si) IL D JM3KE4CY1G0729323 Country Insurance ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 1 99 9 Same P12A8142940 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (D019I (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 ,08 l2024 07 10 ®❑AM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 v 2 ❑ 2 2 11,08 ,2024 06 52 ❑PM ❑Construction * R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ®AM 0 Maintenance U2 o ® 11 4 ARREST NAME Garcia Guerra. Eduardo 11-901 435000693 11,08/2024 06 57 ❑pM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility AM 45 r 2 0 ARREST NAME 11/08 12024 07 56 MPM 0 Unknown work zone type u, 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 435-Mahan. David 502 275-Engelke 12 ,02,2024 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••--, , I I I I A CMV is defined as any motor vehicle used to transport passengers or property and. Y Not To Scale I I I I I N r 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } __ ---; ----- y combination):or INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or < ------:-•-•; _ - transporting3. Is tlgem lloyeeo sl5 or fewer in the course of rye r rs andemployment example:employee a contract X �°' } F p employment�i transporter-usually a van type vehicle or passenger car):or C — '' I. 4. Is used or designated to transport between 9 and 15 passengers,including wwjt i. }-----}---- r,"'r2 - } } } g Po passen rs,includi the driver, , — — for direct compensation(example:large van used for specific purpose):or L t i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m - placarding(example:placards will be displayed on the vehicle). XI m �, I I 4I I CARRIER NAME Z Z I I I ADDRESS O V)_ IIII CITY/STATE/ZIP g I I I I _ MOTOR CARR.ID 0 Interstate ❑ Intrastate I r ❑ Not in Comm./Govt. Not in Comm./Other ❑ 00 --- --4. USDOT NO. ILCC NO. Cm XI Source of above z ❑ 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 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 White Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 0 TOWED BY/TO. 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