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HomeMy WebLinkAbout2024-00073180 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 6 Sheets 01111101111 I01101100 0 lfl 010100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a63854,i u, 1 U21 2 4 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 6 U1 1 U2 1 *P 0 1 1 9 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 El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 202412024-00073180 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 11 19 2024 ®AM ❑YES ®NO U1 LARKIN AVE Elgin01:11 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W N JAN E DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES ❑NIAV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C) FOR DAMAGEDAREA(S) FROM TOWED U1 0A uilera Cortez,Omar 0 9 / yr 13-UNDER CARRIAGE ©,I •:: FIRE ❑ OO r< STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2- 2 n M 2 SY is-OTHER 8 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 �i COM VEH 0 j$J 1 0 ~ ELGIN I L 60123 B 1 0 FIRST CONTACT 1 7_: __5 *Yves.See Sidebar U1 Z EJ82978 IL 2024 REAR TELEPHONE IL D 0 1 G 1 PC5SB2D7309458 UNKNOWN ❑Y 0 N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire Same UNKNOWN 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑Nov 0 I V ❑Dv 1 9 9 2 Ford Fusion 2008 00-NONE 0. Q!'-O DUE TO CRASH rg ❑ 2 x o Yr 13-UNDER CARRIAGE 16 I f: 2 FIRE 0 ® U2 C il M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraction Value 9 0 H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 12 OjNT OF .ji 6 I.;._ ?-5 CIO Ms See SidebarEH ® ut CO ELGIN IL 60123 B 1 0 EHP38712 IL 2024REAR C NA D 0 3FAHP07108R227090 Magnum gly ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Flores :Ledesma,Gustavo,A. ILAA088943900 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 1 3 City of Elgin Stop Sign southeast 11 ,19 ,2024 01 11 ®❑AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) ;, 2 D 29 5 150 DEXTER CT ELGIN IL 60120 2 28 , , PM 0 ❑Construction >F 4 Z 3 ❑ El CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 a 1 ® 11 3 ARREST NAME Aguilera Cortez,Omar 3-707 1508000590 t ! El PM SLMT 1g1 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility t 2 ❑ ARREST NAME Aguilera Cortez,Omar 11-901 1508000591 1 1 r 19 i2024 01 44 0 PM ❑Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1508-Salgiado, Leandro 602 12 , 19,2024 09 00 ❑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••--, , 7Jab?Dr 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 -< i- ;--_.r-_--; INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or C) 0 T, L A Not Scab3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O -•---- - } } . transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a__...I. t 4. Is used or desi nated to trans rt between 9 and 15 ssen rs,including the driver. C I T F } • for direct compensation(example:large van used for specific purpose):or N L L____a____� ` t i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m _ placarding(example:placards will be displayed on the vehicle). XI laean'twvs- unn2 c __ D \ CARRIER NAME Z 7 j1.. ADDRESS D § C) r CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"-------1 - USDOT NO. ILCC NO. m XI Source of above z . • m 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 to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE—