HomeMy WebLinkAbout2024-00074328 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 0011101011
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00a6,3 " ;5
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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 ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 202412024-00074328 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mKI M BALL ST Elgin04:51
® ❑ RELATED ®Y 0 N 11 24 2024 DAM ID YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION III
FT N E S W N SPRING ST COUNTY PROPERTY :IY 2�I N DOORING ❑y #OF MOTOR 0 SLOW 15 '
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 04 n
Y N
0 4 /
yr
Ramirez.Carlos.G. General MotorSiQoq 2009 00-NONE
13-UNDER CARRIAGE ,, • 12 0DUE TOCRASH ❑
10 VI
1 ! 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTHER TAL(ALL) DISTRACTED 0 0U2 04 M322DUNDEEAVE M 2 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASH 0 99-UUNKNOWN 976•TDP3 *DistractionValue 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI S �i 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7 ;- -_5 *II Yes.See Sidebar Ut
Z3839714B IL 2024
TELEPHONE
IL D 0 3GTEK23359G 199797 State Farm ❑Y I$I N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0790267-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 ou
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NI CIRCLE NUMBER(S) U1
/v ❑NCv ❑Dv
!1 9 9 8 Ford Explorer 2007 00-NONE 1 t2 (,�2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TtOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracuon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF . 6 jY COM VEH ❑ ® u1 CO
C
FIRST CONTACT 7 O7 �_j _s •It Yes.See Sidebar
Elgin IL 60123 0 1 0 DV49011 IL 2025 I 0 Si)
IL D 0 1 FM EU758X7UA72761 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Ayala. Katherine. M. ILAA-0738073-02 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
iUNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 06 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 11 /24 /2024 04 51 ®pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 ❑ 07 06 / / ❑PM ❑Construction
Z3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o ® 11 4 ARREST NAME Ramirez.Carlos.G. 11-901-A 1543000026 / / El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 El ARREST NAME 11/24 /2024 05 00 ®PM El Unknown work zone type U1 El AM
3O
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1543-Sturgeon. Kyle 102 12 / 17/2024 01 30 ®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 .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } i IN SPRING ST1—'—'i \\ - i. e. r (example:shuttle or charter bus):or 0
KINISALL
I- I- --I-----� I \� 1 i I }Ors"Nri } } transporting employened to es the course passengers or fewer thir emplod yment example:employeerier X
112471 ®f transporter-usually a van type vehicle or passenger car):or co
L. ° V.V.'''.
C
i. -- aQ _ - 1. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
for direct compensation(example:large van used for specific purpose):or 0
...." t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
d
8 placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
c ._ ADDRESS 0
am 1 rT.
CITY/STATE/ZIP n
MOTOR CARR.ID ❑ Interstate 0 Intrastate 5
r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
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
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
Blue 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE