HomeMy WebLinkAbout2024-00071425 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 0 NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2024I 2024-00071425 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1
® ❑ RELATED ❑Y ®N 11 09 202408:29 ❑YES ®NO U1 -<
LARKIN AVE Elgin08:29
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
75 /MI N E S W North Mclean Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 Cl)
® ® O Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(E)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
FRO TOWED U1
NAME(LAST,FIRST,M) Paz.Vivian.Y. mo yr Q
NT
Chevrolet Trail Blazer 2004 00-NONE 1 DUE TO CRASH 0
Q 12 _
13-UNDER CARRIAGE EN
10 1 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 M
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
❑Y ®N ❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN `Distraction Value 9 ALGN -
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii_6 1, COM VEH 0 Ea 1 C)
1— :FIRST CONTACT 11 7_ —_11_5 *Ilves.See Sidebar U1 0
Z ELGIN IL 60120 0 1 EP26161 IL 2025 REAR . E
TELEPHONE
IL D 0 1 G N ES16S746161499 American Alliance ❑Y ®N U2 1--
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Cruz Garcia.Ademar. E. ILAA093092000 2 m
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 GC)
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 i,uv 0 KO/ 0 Dv CIRCLE NUMBER(S) U1
yr 12 _ 6 x
o 13-UNDER CARRIAGE 10) 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP®*
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN O Oistracllon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s j 6 i,; 4 COM VEH D ® U1 CO
C
FIRST CONTACT 4 7 _. -5 •If Yes.See Sidebar
ELGIN I L 60120 0 1 0 M P22256 I L 2024 REAR Si)
M
IL 0 1 FM5K8AWXPNA03059 Charter Oak Fire Insuranc ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
City of Elgin 8109160P90110 BAC
E
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)
U2 996 r
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1 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 ,09 /2024 08 29 ®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 7 C)
T 2 ❑ 20 99
! 1 ❑PM- ❑Construction *
1
Z3 0 Dyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
a ® 11 1 ARREST NAME Paz.Vivian.Y. 11-709-A 1530000139 / ! El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility
t 2 ❑ ARREST NAME Paz.Vivian.Y. 6-101-A 1530000140 11 109 ,2024 09 10 ®PM El Unknown work zone type U1 30
n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ®AM Workers present? ❑y
30
1530-Soto.Oscar 602 - 12 103 ,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••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I 0combination):
a weight rating more than 10,000 pounds(example:truck or truck trailer 1
} }----------; I I Not_ To Sca_l_e_ I r INDICATE NORTH nation):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I 1 _ } (example:shuttle or charter bus):or
vim` - 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
�D t
i } } } transporting employee In the course of their employment(example:employee X
--- transporter-usually a van type vehicle or passenger car):or w
L L.___a__._3 _ _ St -
4. Isusedordesi natedtotrans rtbetween9and15 ssen rs,indudingthedriver, 'CU
} } for direct compensation(examp large van used for specific purpose):orN_ l l I. L 5. Is any vehicle used to transport anyhazardous material
placarding(example:placards will be isplayed on the vehicle). XI
311111
CARRIER NAME
---- . Z
-- ADDRESS 0
I a I .
CITY/STATE/ZIP C
I I _ i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate 5
I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
r----- ----; el USDOT NO. ILCC NO. m
XI
Source of above z
'
. 0 Yes 0 No ❑ Unknown A
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
to
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
Red Black
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE