HomeMy WebLinkAbout2024-00072665 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 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (8:1B Injury and for Tow Due To Crash
0 AMENDED YR 2024I 2024-00072665 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
® ❑ RELATED ®y 0 N 11 16 202407:50 ❑YES ®NO U1
CONCORD DR Elgin07:50
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
Ixl 0 ®/MI NOS W Packard Dr COUNTY PROPERTY ❑Y ® N DOORING ❑v #OF MOTOR IR SLOW 15 u)
Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
Alvarez.Adrian Honda Accord 2016 00-NONE „ 12 , DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE f IE
al !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ID14 U2 2 m
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
❑Y ®N El UNK VEH. 0 AT CRASH 0 99-UNKNOWN 6 4 `Distraction Value 9 ALGN 2
F CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF l nli COM VEH 0 j$J 1 0
FIRST CONTACT 6 7_:-—1_,--5 *II Yes.See Sidebar U1
Z ELGIN IL 60120 0 1 0 EX11936 IL 2015 RFAR
TELEPHONE
IL D 1 HGCR3F93GA027239 Progressive ❑Y I l N U2 1—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 983245796 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 ivy 0 Ncv 0 DV
!1 9 yf 2 Toyota RAV4 2021 00-NONE ��__' 12 0 DUE TO CRASH rg D
2
0 13-UNDER CARRIAGE 10 2 FIRE El El U2 C
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F 2 4 ❑Y El SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X
N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 il 6 1l, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 1 7 -� _5 *IfYes,See SidebarC
= ELGIN IL 60120 0 1 0 CG81391 IL 2025 REAR 0
IL D 2T3E6RFV8MW019263 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2022141925 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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71
/ , U1 1 D
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 ,16 l2024 07 50 ®❑PM 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 1 C)
T 2 0 30 30
! / 0 PM, 0 Construction *
Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
a1 ® 11 1 ARREST NAME Alvarez.Adrian 11-1402-A 1504000419 / ! ❑PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
25
t 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME y
2 2 3 0 ❑AM Workers present? ❑ 25
1504 Real, Hilario 302 272-Bajak , / ❑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••--, , N ; 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 -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
3. Is designed to`- A carry15 or fewer passengers and operated a contract carrier 0
--- ----; }} } transporting employee �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; �, yam, - •} } } g po pafc rs, or the driver,
for direct compensation(example:large van used for specific purpose):or 0
L i i t _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
i J
Wiz placarding(example:placards will be displayed on the vehicle). XI
ouerm, _ D
%,. CARRIER NAME
\ Z r- ADDRESS0
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Not To Scab f CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate El Intrastate
rnraaaxmnor. 0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
73
Source of above z
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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
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
Black Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE