HomeMy WebLinkAbout2024-00072508 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED El Injury and for Tow Due To Crash YR 2024I 2024-00072508 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP ❑ INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD El In 02:09
® RELATED ®y 0 N 11 15 2024 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day!yr ®PM FLOW CONDITION Ill
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1 O S 1Ar/MI N E M I LDRED Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 Cl)
® Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
ti DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
FOR DAMAGEOAREA(S) RZ'Of1r�TOWED U1 O
Cisneros. Lourdes 1 1 /
yr
13-UNDER CARRIAGE U/ , 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O00
SYSTEM IN ENGAGED 15-OTHER 9 76.71DP 3 DISTRACTED 0 ]$I U2 m
F 2 4 ❑Y ®N ❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN `Distraction Value 9 ALGN •
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,.—i�B �i COM VEH 0 Ea 1 C)
F FIRST CONTACT 11 7_ _t--5 *lIYes.See Sidebar U1 O
Z ELGIN IL 60120 0 1 0 DH45910 IL 2025
TELEPHONE
IL D 5N MS23AD1 LH 163041 NIA El 0 N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 CISNEROS.JOSE. M. NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
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g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV
yr 10 j 12 ( 2 FIRE 0 ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 9 0
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *0istraci on Value
POINT OF s i 4 COM VEH ❑ M U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR : Q FIRST CONTACT 5 O7 ;-_ .OS •If Yes.See Sidebar
z WEST DUNDEE IL 60118 0 1 0 S942985 IL 2025aR 0
IL D 4T1 BB46K38U049583 KANJI ❑y 123 N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 M U HAM MAD.Saleem USI 906200-02 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 rn
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Refused RESPONDER
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(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 El U2Z
N 1 ® 11 1 11 /15 /2024 02 09 ®PM in a Work Zone? ®N DIRP D
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 ❑ 2 99 / / 0 PM• ❑Construction
N 3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a ®1 11 1 ARREST NAME Cisneros. Lourdes 3-707 1506-300 / / El PM SLMT
MI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
o N 0 AM 30
t 2 El ARREST NAME Cisneros. Lourdes 11-902 1506-299 / / pM Unknown work zone type U1
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
2 2 3 ❑ ®AM Workers present? ❑ 30
1506-Nunez. Maria 501 - 12 /10 /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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 <--_.... J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..i.____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
—1::.7
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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
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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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE