HomeMy WebLinkAbout2024-00072535 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a628896
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El5501-51,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2O24I 2024-00072535 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
TECHNOLOGY DR Elgin 03:53
® ❑ RELATED ®Y 0 N 11 15 2024 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W VANTAGE DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (/)❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 6 /
yr
Dudek, Kell P. Chevrolet Malibu 2015 00-NONE ,, 12 , OUE TO CRASH ® ❑
13-UNDER CARRIAGE FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 ]$I U2 0 (T1
F 2 6 0SYTM Y ®SNE El UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 76•TOP�3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a jl COM VEH 0 j$J 1 C)
F. FIRST CONTACT 3 7 _ --_;__5 *IIYes.See Sidebar U1 0
Z Cary IL 60013 B 1 0 EG86085 IL 2024
TELEPHONE
IL D 0 1 G 11 B5SLOFF138994 Allstate ❑Y Il N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
to
99 9 Same 962351705 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
p;rg- DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 N V 0 DV
/2 0 0 6 Nissan Altima 2015 00-NONE 0.. Ql'-0 DUE TO CRASH 0 ❑ 2 x
o y Yr 13-UNDER CARRIAGE 10( i 2 FIRE 0 ® U2 C
M 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 -5 •If Yes.See Sidebar
H ELGIN IL 60123 0 1 EV28229 IL I C
0 Si)
IL 1 N4AL3AP9FC467164 no insurance ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Ordonez Chili, Israel. E. none BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D051 (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 10 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 /15 /2024 03 53 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
2 0 2 28 / / 0 PM• ❑Construction
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
- ® • 0 Utility a, ARREST NAME Dudek, Kelly, P. 11-901 488000213 1 1/15/2024 04 25 Igi PM
oSLMT
U 11 1 MI CITATIONS ISSUED 0 PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM y
t 2 El ARREST NAME Ordonez Chili, David. M. 3-707 488000215 11/15 /2024 05 00 0 PM 0 Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? ❑Y 35
488-Ramos,Arely 901 223-Hughes 12 / 10/2024 01 30 0 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 CNA CMV is defined as any motor vehicle used to transport passengers or property and: ZEl 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
- r INDICATE NORTH combination):or pi
im s BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I x - i.i. e. r (example:shuttle or charter bus):or
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I
. - . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger tl car):or CO
L L.___a____.I ill •4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver, N
— — — I': I — — — } } } for direct compensation(examp large van used for speific purose):or
<____A_---.l Technolo#ytor. - t i. < < i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
r _ I I placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME Z
ADDRESS 0
w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. Not in Comm./Other
I I ---+ ,
USDOT NO. ILCC NO. m
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
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
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
v
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
Gray 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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE