HomeMy WebLinkAbout2024-00075055 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003643673
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00075055 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
239 S MCLEAN BLVD Elgin10:49
® ❑ RELATED ❑Y ®N 11 27 2024 DAM ❑YES El NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 8 !
yr 13-UNDER CARRIAGE I ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
1U O DISTRACTED 0 ]$I U2 4 <<Tl
M 2 SYTM 4 ❑Y ®SNE❑UNK VEH. O ATCRASH 0 99-U 15-UNKNOWN THER9 76•TDP�3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 I,,4 COM VEH 0 0 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 7_: _-5 *II Yes.See Sidebar Ut
Z DK14127 IL 2024 E
TELEPHONE
IL D 0 4T1 G 11 AK2N U636545 Allstate ❑Y ❑N U2 MI—
Al
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same not provided 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
�{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 tiuv 0 NOV 0 Dv
!1 9 9 3 Mazda Mazda 3 2005 00-NONE „ " 12 "_, DUE TO CRASH ❑ 2 x
o - 13-UNDER CARRIAGE FIRE 0 ® U2
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN ''II *OistractonValue 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 1 O 07 ��L 5 COM•I s.EH
See Sidebar❑ ® Ut CO
— Elgin IL 60123 0 1 EY63808 IL 2024 I 0
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IL D 0 J M 1 BK323151227825 Unique Insurance ❑Y ®N RDEFZi
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same I LP3384015 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOE)) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 07 /
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 ,27 l2024 10 49 ®AM in a Work Zone? ®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 C)
2 D 1 3 2 04 11,27 r2024 10 49 PM
® . ❑Construction %
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N O ❑ 18 3 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z 3 ❑AM ❑Maintenance U2
-a, ARREST NAME Lemus Duarte. Luis. F. 11-708 457-580 , r El PM SLMT
o U 1 ® 11 1 ljg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N AM 30
Ti 2 El 3 ARREST NAME Lemus Duarte. Luis. F. 3-707 457-579 , r a pM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
457-Fearol. Megan 601 01 ,07,2025 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
II 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' ® r INDICATE NORTH combination)or p0
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver I - } (example:shuttle or charter bus):or C
X
' A I I _ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
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f, �. - } } } transporting employees In the course of their employment(example:employee
Ma w zena = transporter-usually a van type vehicle or passenger car):or w
`U � saaas.awueenaeiw C
i. }--- ----; I - } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver, (I)
�, for direct compensation(example:large van used for specific purpose):or
L ur i i t } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
! /�ux placarding(example:placards will be displayed on the vehicle). XI
:. : :. :.. ...:.
CARRIER NAME Z
uz I ADDRESS O
T.
CITY/STATE/ZIP C
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ? Not To Scale 1 0 Not in Comm./Govt. 0 Not in Comm./Other 00
�I. ------1 USDOT NO. ILCC NO. C
m
XI
Source of above z
. ❑ Yes II No ❑ Unknown 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
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
White Black
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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE