HomeMy WebLinkAbout2024-00072933 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403f 3o216
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2024I 2024-00072933 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®y ❑N 11 17 2024 ❑AM ❑YES ®NO U1
DUNDEE AVE Elgin07:09
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W LU DA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 to
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
0 7 /
yr 1 2 sJ
13-UNDER CARRIAGE �) 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O2
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 DISTRACTED 0 ]$I U2 m
M 2 8 ❑Y ❑N ®UNK VEH. 9 AT CRASH 9 99-UNKNOWN `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :i1 6 �i, COM VEH 0 Ea 1 C)
F. FIRST CONTACT 12 7_ t-_5 *lIYes.See Sidebar U1 0
Z ELGIN IL 60120 0 1 0 517843D IL 2025 "s
TELEPHONE
IL D 1GCHK74K29F163289 Unique Insurance Co ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire 99 9 Red Stone Landscapin ILC8216817 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 GC)
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 KKv ❑Dv
yr 12 ,_ 2 C
0 13-UNDER CARRIAGE 19( 2 FIRE ❑ ® U2 C
M 2 4 ❑Y El ®
SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16•TOP 3 9 0 X
N UNK VEH. AT CRASH 99-UNKNOWN *Distraction value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5�n'.'O COM(ryes,VEH See Sidebar❑ ® U1 CO11'. 0 FIRST CONTACT 6 O7 _-_Li. O5 •
ELGIN IL 60120 0 1 0 3098841B IL 2025 REAR 0 C
M
IL D 3GTU2MEC9JG428569 Geico ❑y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 6178922974 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
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e occs y
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 !17 l2024 07 09 ®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 5 C)
T 2 0 28 11 11l17 ,2024 07 09 pM
O) ® • ❑Construction 5
,
rw 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Orozco Contreras, Ramon,O. 11-601 475000546 11,17,2024 07 12 ®pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
❑AM 30
r 2 El ARREST NAME ! / ❑PM ElUnknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
2 2 3 0 475-Williarhs. Brianna 102 - 12 !10 ,2024 09 00 D PM Workers present? ®N U2 30
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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or —I
ananw.
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ .:.. -:. j I - (example:shuttle or charter bus):or 0
�= N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
- . - . transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L L.___a__ ,. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y.• . . for direct compensation(example:large van used for specificpurpose):or [he driver,
wane Pe ( P 9 Pe or O
L i — — — II — — — t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
1 r - - I* r r r-----1-
- '1
CARRIER NAME Z
ADDRESS 'n
D
. Not To#cw I
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
.
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'; 0 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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Black
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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE