HomeMy WebLinkAbout2024-00072079 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 11h
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003622622
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00072079 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
MCCLURE AVE Elgin® ❑ RELATED ®Y 0 N 11 13 2024 10:56 ®AM ❑YES ®NO U1 —<
g PRIVATE mo !day!yr ❑PM FLOW CONDITION ITl
FT N E S W LAWRENCEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Igl 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 uuv 0 NV., 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
f4T�TOWED U1 0mo
Murillo.
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 !3 U2 OO M
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4 COM VEH 0 El 1 0
F.
ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar U1
Z CQ26010 IL 2025 Ismi
TELEPHONE
IL D 0 3FADP4FJ6CM102057 State Farm ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2237366SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWESmi 0 v 0 v ❑Dv
!1 9 8 9 Chrysler Town&Country 2011 00-NONE .1.,-1 12-- , DUE TO CRASH ❑ 2 x
0 y13-UNDERCARRIAGE FIRE 0 ® U2
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3 * X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1( 4 COM VEH ❑ ® U1 COFIRST CONTACT 1 7�- -5 •It Yes.See Sidebar
n ELGIN IL 60123 0 1 0 DU92290 IL 2024 I g Sn
Z
IL D 0 2A4RR8DG8BR750056 None ❑Y 0 N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same None BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
iUNIT) ISEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 4 08 / M 2 4 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 4 11 ,13 /2024 10 56 ®❑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 7 C)
T
0 2 ❑ 2 23 , , ❑PM ❑Construction
Z 3 0 Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
a 1 ® 11 4 ARREST NAME Murillo.Jose 11-901-A S1537-000034 ! ! El PM SLMT
•
I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
8 N AM 30
r 2 El ARREST NAME York.Ashley. D. 3-414 S1537-000036 11 i 13 l2024 ❑❑pM ❑Unknown work zone type U1
2 23 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1537-Mapp.Teddron 600 272-Bajak 12 , 31 ,024 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -1
} }-- ''-----' A - r INDICATE NORTH comb nation)or p0
1.1 I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} N - (example:shuttle or charter bus):or
3. Is desgned to car 15 or fewer passengers and operated a contract carrier O
, W } } } transportingemployees In the course of their employment(example:employee X
transporte -usually a van type vehicle or passenger car): r w
i.
(u m . 4. Is used or designated to trans rt between 9 and 15 ge ng cci'}--- ----+ 3 I i • - } } } g po passen rs,including the driver,
I t Maw for direct compensation(example:large van used for specific purpose):or O
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
1 H _ pCITlacarding(example:ZIP placards will be displayed on the vehicle).
XI
CARRIER Y/STATNAMEE/ Z
_ ADDRESS 0w
0
g
-Not To Scale MOTOR CARR.ID 0 Interstate ElIntrastate
0
I I T I __ 0 Not in Comm./Govt. 0 Not in Comm./Other
i- ------1 - USDOT NO. ILCC NO. rTt
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No -
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver 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: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE