HomeMy WebLinkAbout2024-00073680 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II lfl l 00100100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a637225
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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 1215501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00073680 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m401 SUMMIT ST Elgin12:20
® ❑ RELATED ❑Y ®N 11 21 2024 12,— ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 uuv ❑!Cy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) •FROPtf TOWED U1 0
NAME(LAST,FIRST,M) Martinez. Edison mo yr Chevrolet Silverado 2003 00-NONE DUE TO CRASH 0
11 12 -
13-UNDER CARRIAGE } EN
I! 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER O9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r m CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_i L 6 4 COM VEH 0 Ea 1
0
0
F. 0 1 3915102B IL 2025 FIRST CONTACT 10 7 ; _5 *Irves.See Sidebar U1
REAR
Z
TELEPHONE
IL D 1GCEK14X13Z239795 unknown El ❑N U2 I—
M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Carranza Ramirez. Natanael. E. unknown 3 m
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑DV
!2 0 0 4 FROM TOWED
Elantra 2018 oo-NONE 1(' t2 DUE TO CRASH ❑ (� 2 x
_ 13-UNDER CARRIAGE I FIRE 0 El U2
o
c
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9I1,6-TOP 3 9 X
❑Y ❑N ElUNK VEH. AT CRASH 99-UNKNOWN *Oistracti n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i_i, COM VEH 0 ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar
n ELGIN I L 60120 0 1 AT80767 I L 2025 REAR 9
Z
IL D 5NPD84LF1JH359699 Geico ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Rodriguez.Susana 4557779743 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
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1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 r 21 l2024 12 59 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 11 18
N 1 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM
o N ® 11 1 0 •
CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
05
t 2 0 ARREST NAME AM
7 r r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 05
556-Reuter.Craig 301 404-Duffy r r 0 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -'- ' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
e...r,� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
- ----------'1
} } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l 4. lsusedordesi natedtotrans rtbetween9and15 ssen rs,includingthedriver, N
_ } } } for direct compensation(examp large van used for specific purpose):or
McoonMCa r } } •_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
® :0
. placarding(example:placards will be displayed on the vehicle).
—1
Not To Seals i CARRIER NAME Z
ADDRESS 0
V)
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
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: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE