HomeMy WebLinkAbout2024-00073724 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 1111 III 11 III1II IIIIII 01100111100
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 202412024-00073724 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l
DUNDEE AVE Elgin
® ❑ RELATED ❑Y ®N 11 21 2024 12,— ❑YES IX]PRIVATE NO U1
mo /day/yr 04:26 ®PM FLOW CONDITION M
I 0 0/MI N E 0 VY Oakhill Rd COUNTY PROPERTY 0 Y 21N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
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
/8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EoJES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGED AREA(S) Mao TOWED U1 Q
Martinez Gonzalez. Israel.0. 1 1 /
yr
13-UNDER CARRIAGE 16 EN
i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 4 <<Tl
M 9 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASHH D 0 ®-U 15- NKNOWN THER9 76•TOP 3 *Distraction Value 9 ALGN ?
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 I,.4 COM VEH ❑ j$J 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *Irves.See Sidebar Ut
Z CQ62950 IL 2024 REAR
TELEPHONE
IL D 0 1 FMFU18L63LA51214 none ❑v ®N U2 93 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same none 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
x DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV
/1 9 6 5 Ford Explorer Sport Trac 2011 00-NONE ,�_"j Qr-_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 i 1 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 II 6 I',_4 COM VEH ❑ ® Ut CO
Im FIRST CONTACT 6 Y__{_0 -5 •If Yes.See Sidebar
4 ELGIN IL 60123 0 1 0 3327829B IL 2025 REAR 0
IL D 0 1 FMZU7E81 UA33219 Kemper ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 12RA000035432 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDEREl Y ® 9 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 11 / M 2 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 D
/ / 1 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 /21 /2024 04 26 ®PM 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
o"
2 0 22 18 ! / ❑PM• ❑Construction
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME Martinez Gonzalez, Israel,0. 6-101 15440000331 / / ID PM SLMT
oN 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El AM• ❑Utility
t 2 El ARREST NAME Martinez Gonzalez, Israel,0. 11-601-Ax 1544000029 11/21 /2024 04 26 ®PM 0 Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑A-
M Workers present? ❑y 35
1544-Solis,Yulissa 201 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 -<
` ` -' -' - - - 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
ouurm. , 3. Is designed to carry 15 or fewer passengers and operated
�rated a contract carrier O
- ------- i---•
- , }} } transporting employees in the course of their employment(example:employee � X
A.
L I-----}----+ - . } } } transporter sed or des gnated to transport betweelly a van type vehicle or n 9 andr 15rpassen rs,including[he dryer, C
1 �1 h N for direct compensation(example:large van used for specific purpose):or
L L____a____.: I3II - t i. < i. i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
-- placarding(example:placards will be displayed on the vehicle). m
0
2:._
ICI CARRIER NAME
i.
ADDRESS 0
Not To Scale Ii. i. i. T.
r r T 1 ow i i.i ,i CITY/STATE/ZIP 4.
l - i. i. i. MOTOR CARR.ID ❑ Interstate El i. Intrastate
. ❑ Not in Comm./Govt. 0 Not in Comm./Other
--------"1 - USDOT NO. ILCC NO. rn
Source of above z
. If Yes,Name on placard 0
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 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II No 0 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red Blue
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 DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE