HomeMy WebLinkAbout2024-00071922 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110000111011.1110011000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a628846
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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-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00071922 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
BLACKHAWK DR El In 05:09
® ❑ RELATED ®Y 0 N 11 12 2024 ❑AM ❑YES ®NO U1 —<
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FTlMI N E S W CONGDON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 eaves 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FROPtf TOWED U1
Duarte Martinez.Jose. M. Toyota Sienna 2006 00-NONE it 12 , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE .I I! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED ❑ 0U2 2 m
M 2 8 ❑Y ❑SNE®UNK VEH. 9 AT CRASH IN ENGAGED9 99-UUNKNOWN 90:::).TOPO `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ;i� S �i COM VEH 0 j$J 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 3 7 . __5 *II Yes.See Sidebar U1
Z EM60409 IL 2025 Ismi
TELEPHONE
IL D 5TDZA22C26S549616 SafeWay Insurance ❑v ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 4048076-I L-PP-002 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 23N 2 0
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Ncv 0 Dv
!1 9 6 7 Nissan SENTRA 2016 00-NONE O, Qj.O DUE TOCRASH rg ❑ 2 x
0 13-UNDER CARRIAGE FIRE 0 ® U2 C
Ti
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistracJDn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 8 7. i1 I 4 COM VEH 0 ® U1 CO
6 IL5 •It Yes.See Sidebar
Z Streamwood IL 60107 B 1 0 Q668839 IL 2017 I 0 C
M
IL D 3N 1 AB7AP5GY313602 State Farm ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 5835467-F20-13G SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER 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
u 1 ® 11 1 11 ,15 l2024 05 09 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 28 23 11)12 l2024 05 09 ®PM ❑Construction
*
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
oD ® 11 1 ARREST NAME Duarte Martinez.Jose. M. 11-601 475000542 11,12 l2024 05 15 Igi pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
40
t 2 0 ARREST NAME AM
T 1 ! ❑❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 4U
475-Williarhs. Brianna 201 12 , 10,2024 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 e---•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 -<
c ` -'- ' r INDICATE NORTH combination):or -I
IJ I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
L L A j
N 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their empbyment(example:employee
transporter-usually a van type vehicle or passenger car):orCD
L •-----}----; - } } /-
. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
„n,,, i . for direct compensation(example:large van used for specific purpose):or
uKrr O
__ u _ t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires -u
placarding(example:placards will be displayed on the vehicle). XI
- —1
I lir _ CARRIER NAME Z
ADDRESS 'n
D
Not To Scale I C)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘1. - --1 - 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
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 Silver
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: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE