HomeMy WebLinkAbout2024-00075054 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mil l III H IIIl
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003643675'
u, 2 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 5 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00075054 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
S RANDALL RD Elgin 10:38
® ❑ RELATED ®Y 0 N 11 27 2024 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 n
FOR DAMAGEDAREA(S) FROM�TOWED U1 Q
Estrada Candia.Antonio 0 6 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 7 rn
M 2 4 SYTM❑Y ®S NE❑UNK VEH. O AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;iI 6 I,.4 COM VEH 0 Ea 0
F. FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar U1
Z Chicago IL 60608 0 1 ET79198 IL 2025 REAR
TELEPHONE
IL D 1HGCM56363A142238 Safeway Insurance ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3896889-I L-PP-004 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑N,Iv 0 NcV ❑DV
!2 0 0 8 Chevrolet Suburban 2012 00-NONE +i_"i ,z..-_, DUE TO CRASH ❑ C 2
omo 13-UNDERCARRIAGE 10-1 2 FIRE ❑ ® U2 C
il
M 2 4 SYSTEM IN 0 ENGAGED 1 15-OTHER 916•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 6 I,,_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 Y :j_O ._5 •If Yes,See Sidebar
H ELGINZ IL 60124 0 1 CY78084 IL 2025 RE-AR
M
IL D 1 G NSKKE73CR207803 Progressive ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
FUENTES.SUSSAN 937420861 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 08 / M 2 4 0 1 0
m
/ / #OCCS D
/ / U1 1 D
/ / 2 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 r 27 /2024 10 39 ®pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 08 03 + r ❑PM ❑Construction >F
Z 3 ❑ Dyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM Maintenance U2
❑
-a, ARREST NAME Estrada Candia.Antonio 11-601 752463 ! r ❑PM SLMT
o U 1 ® 11 1 ISI CITATIONS ISSUED 0 PENDINGTIME ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 50
t 2 El ARREST NAME Estrada Candia.Antonio 11-501-A-1 752462 r r pM Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
340-Phillips. Kathryn 800 11 r 12 r25 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
I I ItI� -<
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
i- -----------; II I I ( combination):or —I
INDICATE NORTH P1
I ■, I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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Tb Scal } (example:shuttle or charter bus):or 0
a I4 [. X
' �' 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
LL.__-A-. - } } } transport) em loyees in the courses of their em yment example:employee X
transporterg-usually a van type vehicle or passenger car):or
I t J Q co
L 4. Is used or designated to transport between 9 and 15 passengers,including wwjt
}-----;----+ � - } } } g po passen rs,includi the driver,
I — — — — — — for direct compensation(example:large van used for specific purpose):or O
L L--_-a-....l 'N. c= - l. i } I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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S' placarding(example:placards will be displayed on the vehicle). Zmt
r D
CARRIER NAME Z
,� - ADDRESS O
- - -� (
I I a . .I-T 11a c- 1 CITY/STATE/ZIP g
,
I I I , MOTOR CARR.ID 0 Interstate 0 Intrastate 5
, I I Not in Comm./Govt. Not in Comm.lOther
0 0
; _Y_._.; r 1 USDOT NO. ILCC NO. m
XI
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
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 E
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE