HomeMy WebLinkAbout2024-00073212 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4036 a0266
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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 ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
El AMENDED YR 2024I 2024-00073212 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD Elgin07:37
® ❑ RELATED ®Y ❑N 11 19 202407:37 ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W MAPLE LN COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 Cn
❑ Kane HIT&RUN ❑V ® 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 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FROf'rr TOWED U1
NAME(LAST,FIRST,M) mo yr O
Valdivia Muniz. Petra Chevrolet Malibu 2005 00-NONE 11. DUE TOCRASH ® ❑
Q
13-UNDER CARRIAGE 16 i : 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 0 m
F 2 5 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
❑Y ®N DUNK VEH. 0 AT CRASH 0 99-UNKNOWN `Distraction Value ALGN =
1• CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 I, 4 COM VEH 0 Ej 1 n
I- FIRST CONTACT 12 7_•—t--5 *II Yes.See&debar Ut O
Z E LG I N IL 60123 0 1 0 BX28324 IL 2025 HEAR
TELEPHONE
IL D 0 1G1ZS52F95F335206 State Farm Mutual ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same 1033546-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 c
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 NCv ❑DV
yr 12 ._ 2 C
Ti 13-UNDERCARRIAGE 10! 2 FIRE ❑ ® U2 C
M 2 6 SYSTEM IN O ENGAGED 0 15-OTHER 9 1,6-TOP®* 0
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN O Oistracton Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i_.,_4 COM VEH ❑ ® U1 W
FIRST CONTACT 3 7 . _� _5 •If Yes.See Sidebar
F= ELGIN IL 60123 0 1 0 EQ94917 IL 2025 REAR 0 N
IL D 0 4T1BF30K75U110369 PROGRESSIVE ❑y 123 N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 963808472 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 4 11 ,19 l2024 07 37 ®❑PM in a Work Zone? ®N DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
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0 2 ❑ 2 14 ) ! 0 PM ❑Construction
R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Valdivia Muniz. Petra 11-902 W319001064 ! ! El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
30
1 2 ARREST NAME AM
1 r ❑❑
T PM 0 Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
❑AM Workers present? ❑ 30
2 2 3 0
319 Ross.Adam 602 272-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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; 1.as atloeign):htratingmorethan10,000pounds{ xamp :truckortruckrtrailer 1 e le �
1 8' 9[= 0 Not To Scale INDICATE NORTH C
3= 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
- r r r (example:shuttle or charter bus):or 0
L I- -A- --; avo - . - . transporti3. Is ng employeesned to Inthe course passengers or fewer thir emplod yment example:employeerier 73
an .n,.'•.% an transporter-usually a van type vehicle or passenger car):or CD
{,F�/ all) =_,. anC
L L.___a__...I. — — — � — — — — - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. w
[� _:} t } • •
for direct compensation(example:large van used for speific purose):or N
L L--_-a-___.I u"RZ L.Imr2 - t i. < . • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
t ADDRESS
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CITY/STATE/ZIP n
g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y._._; USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE