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HomeMy WebLinkAbout2024-00071277 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 1111111111111111 1111111111111111111111111111011 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003622535 u, 1 U29 3 4 1 U1 2 U299 U, 1 U299 U1 1 u2 99 4 10 u1 4 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash El AMENDED YR 202412024-00071277 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 11 08 2024 ❑AM ❑YES ®NO U1 N RANDALL RD Elgin11:44 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 to ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 WIN 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 1 0 / yr ©1 12 - 13-UNDER CARRIAGE 1 I! 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m F 2 SYTM 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I, 4 COM VEH 0 0 1 0 ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z ER32530 IL 2024 REAR TELEPHONE UNK. Other 0 JM1BK32F381833674 Safeway Insurance ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m MUGNO. NICOLAS. E. 4081675ILPP002 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 use 0 N v 0 Dv yr Unknown Unknown oo-NONE ,i_ t2 DUETOCRASH p El99 Ti 13-UNDER CARRIAGE FIRE El El U2 c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 -O DISTRACTED ❑ ® SPDR n SYSTEM IN ENGAGED 15-OTHER 9.16-TOP 3 a ❑ ❑ 9 9 9 Y ❑N UNK VEH. AT CRASH 99-UNKNOWN *Ois/recu n Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-iI 6 i_i, 4 COM VEH D ® U1 CO 1.* FIRST CONTACT 1 7� _-5 O. If Yes.See Sidebar C 0 9 0 rFAR 9 ti M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 NIA ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X MUGNO. NICOLAS. E. NIA BAG $ 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 El 11 4 11 !09 r2024 11 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 3 n T 2 ❑ 2 99 ! r ❑PM• ❑Construction o R 1 3 ❑ $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -a, ARREST NAME Rodriguez Maldonado. Britny. M. 11-901.01 1502-000271 r ! El PM SLMT o N 1 ® 11 9 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility AM 50 t 2 ❑ ARREST NAME Rodriguez Maldonado. Britny. M. 6-101-A 1502-000270 ! r 0 PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 1502-Camiacho. Fernando 502 12 ! 17 r2024 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` -' -' r INDICATE NORTH combination)or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ .:.. -:. i li Li _ } (example:shuttle or charter bus):or T,I ncaIs. w J. 3. Is desgned to carry 15 or fewer passengers and operated by a contract corner I O - } } } transporting employees in the course of their employment(example:employee 73 transporter-usually a van type vehicle or passenger car):or w C < <.___a____.l 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including (I) } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L ) 5,,. IP C I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m B ,r,y. placarding(example:placards will be displayed on the vehicle). - - -emu."`1- D ' '�1, + CARRIER NAME —I ADDRESS 0D rn Not To Scale CITY/STATE/ZIPn I I i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate - I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 0 Yes II No ❑ 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 71 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 Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. _Redmons/Impound Lot Garage . 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