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HomeMy WebLinkAbout2024-00075224 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I01101100 0 III I1*110110011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03643828 u, 1 u29 1 1 1 U116 U2 1 u, 1 1_12 1 u, 1 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash El AMENDED YR 202412024-00075224 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ADAMS ST Elgin ® ❑ RELATED ®Y 0 N 11 29 2024 ®AM ❑YES El NO U1 PRIVATE mo /day/yr 02:26 ❑PM FLOW CONDITION m • �O 1C.'J!MI N E S © LI N DBERG H Ct COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA Kane HIT&RUN I�I V ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 18:DRIVER p PARKED 0 DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 6 / yr Chevrolet Impala 2008 00-NONE 11;• ! 0O 12 DUE TOCRASH ® 0 1�3 UNDER CARRIAGE 10 I 2 FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m F 2 4 El ®SNE❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UUNKNOWN 9 76-TOPO `DistractionValue 9 ALGN = r •CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 �i COM VEH 0 0 1 n F. FIRST CONTACT 1 7 _---_;__5 *Yves.See Sidebar U1 0 Z ELGIN IL 60123 0 1 0 EE40047 IL iismi TELEPHONE IL 0 2G 1 WT55N 181255400 Unknown ❑v ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Morales. Manuel Unknown 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 73 p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr Ford F250 2008 00-NONE 11 '12'.--1 DUE TO CRASH ❑ 2 �7 13-UNDER CARRIAGE FIRE 0 El U2 iiic0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 ® SPDR 0 a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I . 4 COM VEH 0 ® U1 to FIRST CONTACT 7 t j L5 •If Yes.See Sidebar C 3998048B IL REAR 0 fp M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTSW21 R98EA89663 Kemper ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Jaime.Jose.A. 12RA000009167 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 1 11 ,29 ,2024 02 26 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1 o" 2 0 28 18 ) ) ❑PM, El Construction * Z3 ❑ CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 o 1 ® 11 1 ARREST NAME Morales.Vanessa 11-601 S1510000507 , r ❑PM SLMT • I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑utility 8 N ❑AM 30 t 2 El ARREST NAME Morales.Vanessa 3-707 S1510000509 , r ❑PM ElUnknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1510-Cortes. Reyna 701 01 ,27,2025 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 truckrtrailer -< c ` --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 L A 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 X transporter-usually a van type vehicle or passenger car):or w L 4. Is used or desi nated to trans rt between 9 and 15 ge ng N}-----}----; - } } } g po passen rs,includi [he driver, for direct compensation(example:large van used for specific purpose):or O L L____a____.I i MI_Tilffi'L.: _ t i L i t 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires Y placarding(example:placards will be displayed on the vehicle). XI D Adems?St , , , , , CARRIER NAME iIr ADDRESS '0 Untt 2 as V) �!f? n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"-----"1 - USDOT NO. ILCC NO. m XI Source of above z ' . MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 Silver White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 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: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE