HomeMy WebLinkAbout2024-00072783 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2024I 2024-00072783 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED ®Y ❑N 11 16 2024 ❑AM ❑YES ®NO U1 -<
DUNDEE AVE Elgin 08:31
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W 190 RAMP COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
T�TOWED U1 0NAME(LAST,FIRST,M) mo yr
Acbal.Alvaro.G. Honda CRV 2005 00-NONE 0 >2• �/DUE TOCRASH ® ❑
13-UNDER CARRIAGE 1U 1 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 0 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 6 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_: __5 *lives.See Sidebar U1
Z EL15852 IL 2025 E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
0 SHSRD78535U344105 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Alvarez Tinajero. Brayan. U. 12AU001550806 1 I—
t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
m E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
1 9 yf 5 Ford Escape 2013 00-NONE 11_. 12�"_, DUE TO CRASH 0 D 2
0 13-UNDER CARRIAGE o I 2 FIRE 0 ® U2 C
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M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF s i 4 C.OM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 �.' C
FIRST CONTACT 9 7 _,__5 *IfYes,See Sidebar
Niles IL 60714 B 1 0 Z640728 IL 2024 I 0 Si)
IL D 0 1 FMCUGH96DUB53951 StateFarm ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Peralta. Blanca 2864672SFP13 BAc $
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)
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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 ,16 /2024 08 31 ®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)
Eri 2 0 25 40 11,16 ,2024 08 33 ®PM ❑Construction
E
R O 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Acbal.Alvaro.G. 6-101 S1515000455 11/16/2024 08 37 ®PM• El Utility SLMT
I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
o t 2 El ARREST NAME Acbal.Alvaro.G. 11-305 S1515000456 11/16 /2024 08 50 0 PM El Unknown work zone type U1 15
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0
AM Workers present? ❑Y 15
1530-Soto.Oscar 201 12 ,03,2024 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 unitshave 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
0 .
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer T.
/ / Not TO Scale INDICATE NORTH C
III
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
} A
/ /
i 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
® } } } transporting employee �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
-- -- } } } C
•4. Is used or designated to transport between 9 and 15 passengers,including the driver. to
.--'------u---
nit`2 for direct compensation(example:large van used for specific purpose):or o
) t i. i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires ill
C. m
placarding(example:placards will be displayed on the vehicle).
D
/ wr CARRIER NAME Z
/ � ADDRESS0
Unit 1 >
/ O
/ CITY/STATE/ZIP o
/ - MOTOR CARR.ID 0 Interstate ❑ Intrastate
- / ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
;....Y. .. 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
Tan Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 4 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE
DUE