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HomeMy WebLinkAbout2024-00072537 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets II III HH II11II OUI 00110001HHI DIII 1 fli 100100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X'6D3,?28Pr9! u, 1 U21 1 1 1 U1 2 U2 1 u, 1 1_12 1 u1 1 U2 1 3 10 u, 4 u2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash El AMENDED YR 202412024-00072537 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n WATCH ST El In04:13 ® ❑ RELATED ®Y 0 N 11 15 2024 12,— ❑YES El NO U1 —< g PRIVATE mo !day/yr ®PM FLOW CONDITION m FTlMI N E S W WELLINGTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 /83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Valle-Tapia. Minerva.V. 0 2 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SYTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 16-TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 �i COM VEH 0 Ea 2 O ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_; __5 *II Yes.See Sidebar U1 ZBT61939 IL 2021 E TELEPHONE IL D 0 1 FAHP35N48W263224 Allstate ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 802273731 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 D Refused ❑Y ElN 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES O NMV 0 NOV ❑DV !1 9 6 3 Chevrolet Suburban 2017 00-NONE OI t2 c 2 DUE O CRASH 0 D U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i1 4 A 6 �i COM VEH—REAR _5 •If Yes.See Si ❑ ® U1 W debar I- BATAVIA IL 60510 0 1 0 Y858010 IL 2025 FIRST CONTACT 11 7 IL D 0 1 G NSKH KC9H R265958 State Farm ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 0357569sfp13 BAG $ 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) 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 (15 l2024 04 13 ®AM 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 8 C) F.; T 2 ❑ 2 99 / / 0 PM- ElConstruction X R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMSARRIVED TIME 5 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Valle-Tapia. Minerva.V. 11-1205 1545000042 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility 15 t 2 ARREST NAME AM T ( r ❑❑PM 0 Unknown work zone type U1 El 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15 1545-VanEycke. Brier 401 12 , 17(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 ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z kycl, ,1-77.7.7.-7n 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< Y Not ToINDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C : Scale , - (example:shuttle or charter bus):or 0 L A I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 I r - } } } transporting employees In the course of their employment(example:employee X ars transporter-usually a van type vehicle or passenger car):or w rA C L -----}---- �;,' :; - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used fors cific purose):or I I S o L L____a____.I rya, _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z r r -1- 1 r ADDRESS 'n C) , CITY/STATEJZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. Not in Comm./Other -Y- � USDOT NO. ILCC NO. m—1 XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 g 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 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 Gray Maroon 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: 2 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE