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HomeMy WebLinkAbout2024-00073306 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 II lfl VOID fll 1100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4036 37:96 u1 1 u21 1 1 1 U1 2 U299 u1 1 U2 1 U199 U2 99 1 12 u, 18 U2 1 *P0119* 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 ❑$501-$1.500 ®ON SCENE 11 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00073306 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 19 2024 ❑AM ❑YES ®NO U1 -< RT20 WB Elgin mo /day/yr 03:31 ®PM FLOW CONDITION m _ Eg50 CJ © COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 6 (n !MI N E $ State St WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 ROPTT TOWED U1 0 Almanza.Vivian.Y. Mazda CX-3 2011 00-NONE ,, 12 , OUETOCRASH 0 NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE EN O i FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED ® 0 U2 2 m M 2 4 SYM IN ENGAGED 15-OTHER ❑Y ®N SE❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN 016 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D;i�6 4 COM VEH 0 Ea 2 O F. Hammond IN 46327 0 1 0 FIRST CONTACT 10 7 ; -5 *IfYes.SeeSidebar Ut Z TLL717 IN 2023 TELEPHONE IN B 0 J M 1 BL1 VF7B1389493 Progressive ❑Y ®N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Almanza.Vivian 974997147 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MKAV 0 V ❑Dv /1 9 yf 9 Chevrolet Silverado 2023 00-NONE ,i_j 12'-_, DUE TO CRASH ❑ ® 14 x 0 13-UNDER CARRIAGE 10 l z FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 4 s I 4 COM VEH El ❑ U1 CON CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _ _ ,',_ FIRST CONTACT 2 7._:._, _5 •If Yes,See Sidebar C Lena IL 61048 0 1 0 209101 H IL 2025 REAR 4 N IL C 0 1 HTKJPVM7PH402896 Starr Indemnity and Liabi ❑v J N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Bluff City Materials 1000679509241 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 08 / M 2 4 0 1 0 m / / #OCCS D / / UI 2 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z N 1 ® 11 1 11 ,19 /2024 03 31 ®AM in a Work Zone? ❑N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n T o" 2 ❑ 2 28 / / ❑PM- ElConstruction Z3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 o ® 11 1 ARREST NAME Almanza.Vivian.Y. 11-601-Ax 1525000394 / / El PM SLMT o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM T 2 El ARREST NAME 1 1/19 /2024 04 24 ®PM El Unknown work zone type U1 45 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1525-NavE.Oscar 701 12 , 17/2024 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••--, , ; 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 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X A 0 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 Not Tb Scala i transporter-usually a van type vehicle or passenger car):or w L 4. Is used or designated to transport between 9 and 15 passengers,including N}-----}----; - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O L - t i. i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III ® placarding(example:placards will be displayed on the vehicle). XI m ..1,_ ®® I CARRIER NAME Z �r irk'.=® _ __ ADDRESS 'n 'Uaa 1 — CITY/STATE/ZIP I 0 I MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----'Y----1 - USDOT NO. ILCC NO. rn XI Source of above z . own tank)? 0 Yes ® 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 ®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 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black White 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE