HomeMy WebLinkAbout2024-00072820 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003628913
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00072820 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 11 17 2024 ®AM ❑YES ®NO U1
CONGDON AVE Elgin01:55
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT l MI N E S W DUNDEE DEE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NW 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 1 /
yr 13-UNDER CARRIAGE i FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 2 rr1
M 2 SY4 ❑Y CITM NE
®UNK VEH. 9 AT CRASH 9 99-U 15-UNKNOWN THER O9 18.70P 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF il_6 I,.4 COM VEH 0 E! 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 10 7 ; _5 *II Yes.See Sidebar Ut
Z EG56485 IL 2024 REAR
TELEPHONE
IL D 0 1 N4AL2AP8CC182803 American Alliance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA-100508900 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 73
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW 0 Ncv ❑Dv
!1 9 9 6 Toyota FJ Cruiser 2013 00-NONE i1_"I Qi O DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10( 12 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 1,6-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `0istraglon Value 0
POINT OF S i1 �i 4 COM VEH ❑ ® U1 IN
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6
FIRST CONTACT 1 7�- -5 •If Yes.See Sidebar
— Elgin IL 60120 0 1 0 BV36846 IL 2024 REAR
0 N
D
IL D 0 J F1 ZNAA12D2712029 nja ®V ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Hernandez.Olivia nla BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS))(TELEPHONE) (EMS) (HOSPITAL)
2 3 09 / F 2 4 0 1 0
m
/ / #OCCS D
/ / U1 1 D
/ / 2 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 ;17 /2024 01 55 ®❑pM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 28 99 / / ❑PM, 0 Construction *
R 3 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
-a, ARREST NAME Olea Delgado.Jordy.Y. 11-601 S1522-200 ! ! El PM SLMT
o U 1 ® 11 1 0 CITATIONS ISSUED 0 PENDINGTIME ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 45
r 2 El ARREST NAME Olea Delgado.Jordy.Y. 6-101 S1522-199 , / pM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 45
1522-Velazquez. Noeli 201 12 , 91 /024 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 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 -<
c ` --I -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ®" - (example:shuttle or charter bus):or 0
i r r J 1 [
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I. I- 1- transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or COL L.___a____JI '
«e `"�0°' } } C
4. Is used or designated to transport between 9 and 15passengers,including the driver, N
in* I. direct compensation(example:large van used for specific purpose):or
L L____a____.: , 1 - l. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires u
f placarding(example:placards will be displayed on the vehicle). m
A
D
i I CARRIER NAME Z
1 ADDRESS D
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Mwm&uA I I C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- -'4 - USDOT NO. ILCC NO. m
XI
Source of above 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?
❑ Yes II No ElUnknown A
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 E
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 White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE