HomeMy WebLinkAbout2024-00071478 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
I01101100 II lfl III fl II 1100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036 3G206
U12 U2 1 1 1 U1 8 U2 U1 1 U2 U1 1 U2 5 5 U1 1 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
20241 2024-00071478 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
E CHICAGO ST Elgin 03:43
® ❑ RELATED ❑Y ®N 11 10 202403:43 ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
1�5 /MI N E S 1Ar South S LibertyCOUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ®SLOW Cl)
® Sq Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Hi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Callejas Ruiz. Ricardo.J. mo1 /
13-UNDER CARRIAGE 16 O,._Z FIRE 0 ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 t6-TOP 3
❑Y ®N ❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN `Distraction Value 1 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6._iL 6 4i,4 COM VEH 0 g! 1 C)
F. FIRST CONTACT 12 7_:—_t-_5 *II Yes.See Sidebar U, 0
.... ELGIN IL 60120 0 1 0 2386526B IL 2023 REAR
TELEPHONE
IL 0 1 GTEK19R2WE522227 None ❑Y 0 N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co
Same None 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2
rg-
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
yr 12 - C1
o 13-UNDER CARRIAGE 10.i t, 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ 0 SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value POINT OF 8 0
-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-5 CIO e1sVSee SidebarEH ❑ ❑ U1
• C
CO
1.. ---- co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 995 <
RESP❑YO❑N NDER U1 Z
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
m
/ / U1 01 ' m
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CD 2 11 ,10 ,2024 03 43 ®❑AM
in a Work Zone? NJ DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: U1 5 C)
T 2 0
08 28 ❑AM
! ! ❑PM- ❑Construction >F
t
Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Callejas Ruiz. Ricardo.J. 11-601 752427 ! r ❑PM SLMT
o u 1 ❑ B!CITATIONS ISSUED 0 PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM 0• Utility 30
t 2 ❑ ARREST NAME Callejas Ruiz. Ricardo.J. 3-401-A 752430 11!10 ,2024 04 00 [M PM ❑Unknown work zone type U1
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1511-Ayala. Roberto 300 12 !20 /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.
. 0
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 truckrtrailer -<
N combination):or -1
r } r---- ----, - r INDICATE NORTH P1
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
E?Qacaca?et ; T,
L --I--
Ai B1
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.I 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe p pose):or o
L t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'I
Y^°'Z placarding(example:placards will be displayed on the vehicle). XI
m
A.
I CARRIER NAME Z
ADDRESS 0
D
ua i se
Not To Scale to
4 •1 w
+ - CITY/STATE/ZIP g
4 - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
cn
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
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_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE