HomeMy WebLinkAbout2024-00073771 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
I01101100 'IIIIII 1110IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a6,3 8
u, 9 U29 1 1 1 U1 2 U2 1 U199 1_12 1 u,99 U2 1 5 9 u, 1 U222 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ®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 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00073771 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
357 S BELMONT ST Elgin08:45
® ❑ RELATED ❑Y ®N 11 21 2024 ❑AM ❑YES IX]NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER O PARKED D DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Unknown.0. Unknown Unknown 00-NONE 11 . 12 DUE TOCRASH ❑ VI
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE NI
101 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 ❑ ' 2
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
6 a r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -,)�6 �i,_ COM VEH 0 j$J 1
I� 0 9 0 FIRST CONTACT 1 7 ; _5 *IIYes.See Sidebar U1 0
REAR
c Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
unk ®Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unk 2 1—
"5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 DV
yr Nissan Sentra 2015 00-NONE 'o.•r t2 (,-2 FIRE DUE o CRASH ® U2 1 C o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.is
3 0 ® SPDR n
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN ••0istraetlon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j�',_ COM VEH ❑ ® CO
F,,, FIRST CONTACT 7 Q __,�_5 •If Yes.See Sidebar
EE53547 IL REAR0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3N1AB6AP1 BL685289 Alliance ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Castillo Jimenez. Eduardo ILAA086900101 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
)UNIT! (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 1 08 / F 1 4 0 1 0
m
/ / #OCCS D
Xl
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 11 ,21 /2024 08 45 ®pm in a Work Zone? Igi 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 04 28
N 3 ❑ CITATIONS ISSUED 0 PENDING + ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
-a, ARREST NAME / / ID PM '
1 ® 1 1 1UtilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME 0
❑CITATIONS ISSUED PENDING
r 2 El ARREST NAME 1 1/21 /2024 08 45 ®PM 0 Unknown work zone type U1 30 El AM
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
0 Y 30
488-Ramos.Arely 702 334-Fries / / ❑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 unitshave 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
:.. A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
• I - } } } transporting employees in the course of their employment(example:employee X
Ell ID
N transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N
} } } g po passen rs,includi [he driver,
w for direct compensation(example:large van used for specific purpose):or O
.J
l. l I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a placarding(example:placards will be isplayed on the vehicle).
m
r r "" CARRIER NAME Z
ADDRESS 0
w
Starrford7Ck n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate DO
Intrastate
I I T ❑ Not in Comm./Gout. Not in Comm./Other
Not To Scale ❑
;____Y___. USDOT NO. ILCC NO. M.(
73
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE