HomeMy WebLinkAbout2024-00068369 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mil l III H IIII
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00068369 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
RT20 [1 ❑ RELATED ®Y 0 N 10 26 2024 05:39 ❑AM ❑YES ®NO U1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Ptf
CARMONAARIZMEND!.CESAR 1 1 /
yr 13-UNDER CARRIAGE IE
fal !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 78•TOP 3 ,Distraction Value 9 ALGN =
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CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRISTNTOONTACT 12 Y!{:®}•_,5 COM
VEH See Sidebar U,Ea 1 0
Z Streamwood IL 60107 0 1 0 3353446B IL 2024 I
TELEPHONE
IL D 0 1 GCEK14T22Z338010 American freedom ❑Y Il N U2 19 , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12-2208637-07 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ® N 2 0
g DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NI AV 0 Ncv 0 DV
0 0 1 FROM TOWED
Kicks 2018 00-NONE i1_"j Q�,-_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10( I FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,is-TOP3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 8i1 Ii 4 COM VEH ❑ ® U1 CO 7 B L5 •If Yes.See Sidebar
— Elgin IL 60124 0 1 0 EP58489 IL 2025 REAR0 N
IL D 3N 1 CP5CU3J L498674 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1852841-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ❑ 11 1 10,26 /2024 05 39 ®AM 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 C)
57 2 ® 11 1 28 99
! / ❑PM• ❑Construction *
Z3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a CARMONAARIZMEND!.CESAR 11-601 457-564 / / PM
-, ARREST NAME ❑
o U 1 ® 1 1 1 CITATIONS ISSUED 0PENDING TIME • 0 Utility SLMT
o NSECTION CITATION NO. ROAD CLEARANCE AM 55
t 2 El NAME Rocha.Jessica 11-601 457-563 / , 0 PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? D Y 55
457-Fearol. Megan 401 11 , 12/2024 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.
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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 -<
} }---.r----; combination):or —I
INDICATE NORTH p1
a, 1 ` i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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_ } (example:shuttle or charter bus):or Cr
r r ror,o m...�' , 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- <.__-A..- -: _ ` - y } } } transport) employees In the course of their employment
transporter- a van vehicle or (example:employee
Po usually type passenger car):or c0
L ----A----; _ s e - I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or
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L___..i.. � "" '� •= u - i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
d -�� placarding(example:placards will be displayed on the vehicle). XI
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'� _ CARRIER NAME
// _ ADDRESS 0/ _ D
CITY/STATE/ZIP 0
.........4°.....°9„"/:/
r i./ MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 ❑ Not in Comm./Govt. Not in Comm./Other 00
1 ❑
; _Y_ _..; USDOT NO. ILCC NO. m
XI
Source of above z
.
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
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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
Beige White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE