HomeMy WebLinkAbout2024-00072022 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00072022 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 mDAMISCH RD El ❑In RELATED ❑Y ®N 11 13 2024 05:52 ®AM El YES ❑NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
1/4 Erie N E S W Highland Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® O g Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Franco.Andres. D. mo Honda Odyssey 2009 00-NONE ,1,_ Oi_, DUE 7oCRASH ❑
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13-UNDER CARRIAGE 10 ' 2 FIRE 0
2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH 0 j$J 4 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar Ut
Z Q741762 IL 2025 REAR
TELEPHONE
IL D 5FNRL38449B413089 Sate Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Franco.Jose.G. 1788723SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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g DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 M/V 0 NOV 0 DV
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0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
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❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i1 . 4 FIRST CONTACT 12 7 B 1!.5 *COM VEH(ryes,See Si ❑ ® U1 COdebar
= PINGREE GROVE IL 60140 0 1 0 CY41452 IL 2025REAR
IL D 3VWC57BU4MM061231 Safeco ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same Z5253647 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND Y ❑N 3 U1 =
(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 ® 15 1 Department of Natural Resources female deer 11 ,13 /2024 05 52 ®❑pM in a Work Zone? ®N DIRP co
I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1
5- 2 ❑ 1 NATURAL RESOURCES WA5'pringfieldL 62702 21 21 , , ❑PM ❑Construction
ZJ 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
-a, ARREST NAME / / ❑PM '
o N 21 1 5 1 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
r 2 0 ARREST NAMEAM
T ( / PM 0 Unknown work zone type 50
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 901 404-Duffy r / ❑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 —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
I- :- -- ----; - transportingd employeesned to alIn the course of 5 or fewer passengers
e e ano example:employee a contract ner X
} } } transporter-us employment
'�� nspOrtet wally a van type vehicle or passenger car):or co
L L.___a____� ` } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
s for direct compensation(example:large van used for specific purpose):or
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L _r l. i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
0 placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME Z
ADDRESS D
0 0
i. i. i. i. 4.
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CITY/STATE/ZIPg
I Not To Scala MOTOR CARR.ID 0 Interstate 0 Intrastate
I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
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Source of above z
. ❑ Yes [J No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No -
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
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LOCAL USE ONLY TRAILER VIN 2 m
0
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
Gray Gray
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE