HomeMy WebLinkAbout2024-00073094 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II lfl N ��I fli II 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a632692
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY N OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2O24I 2024-00073094 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
® ❑ RELATED ®Y 0 N 11 18 2024 ❑AM ❑YES N NO U1
ILLINOIS AVE Elgin02:54
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y N N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST N N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0FOR DAMAGEDAREA(S) FROr tf�TOWED U1 0Gonzalez Perdomo.Alida 1 1 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 N U2 0 rrl
F 2 4 ❑Y ®SNEM Uis-OTHER
NK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it B 4 COM VEH 0 N 1 0
F• Elgin IL 60120 0 1 0 FIRST CONTACT 12 7_;1 __5 *II Yes.See Sidebar Ut
Z 9 CV78191 IL 2025 REAR
TELEPHONE
IL D 0 3C4PDCAB9DT690649 Bristol West ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same G01285232403 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y N N 2 0
g DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMv 0 NOV ❑DV
!1 9 yf 8 Ford Focus 2013 00-NONE N_' 12._-Y1 DUE TO CRASH rg ❑ 2 73
o - 13-UNDER CARRIAGE I 1.J FIRE ❑ ® U2
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y i N El UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
POINT OF s i1 . 4 COM VEH 0 N U1 IN N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1 5 �f_
FIRST CONTACT 1 Y _, _5 •(ryes.See SidebarC
n ELGIN Z IL 60120 0 1 0 CM32828 IL 2025 I 0
IL D 0 1 FADP3F25DL122953 Geico ❑Y N N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 6011748933 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
ut =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 11 ,18 ,2024 02 54 ®AM in a Work Zone? NI N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 23 99 11,18 ,2024 03 09 N PM ❑Construction
*
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Gonzalez Perdomo.Alida 11-1204-B 1545000043 11,18,2024 03 14 N pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
T 2 ARREST NAME AM
7 , ! ❑❑PM El Unknown work zone type U1
El
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1545-VanEycke. Brier 401 334-Fries 12 ,21 ,7202 09 00 ❑PM N 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
0
ADDITIONAL UNITS FORMS.
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A CMV is defined as any motor vehicle used to transport passengers or property and: Z
14 7Iri�) 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` -' -' r INDICATE NORTH combination)or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale I - (example:shuttle or charter bus):or 0
L A 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
rter-
enger
L L.___a____.l t 42lsuosedordesgnatedtotrans vehicle
rtbetween9a d15rpa or c0
ssen rs,includingthedriver. C
J ` } } for direct compensation(example:large van used for specific purpose):or 0
L L--_-a r I' - i. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
Unit 1 1 I placarding(example:placards will be displayed on the vehicle). ,Zmt
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1 C _ CARRIER NAME
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ADDRESS 'n
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0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT 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: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE