HomeMy WebLinkAbout2024-00074340 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X40a645256
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 2
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
®AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00074340 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 11 24 2024 ❑AM ❑YES ®NO U1 -<
SUMMIT ST Elgin mo /day/yr 06:07 ®PM FLOW CONDITION M
E050 ®/MI N 0 S W Dundee Ave COUNTY PROPERTY El'COUNTY ® N 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 IZI N ® FREE FLOW # LNS 0
(8: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 5 n
FOR DAMAGEDAREA(S) O
FRONT TOWED U1
0 1 /
yr Q Q -
13-UNDER CARRIAGE 1 EN
1 , FIRE 0
0 2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 5 r<Il
M 2 3 SYTM❑Y ®NNE DUNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I,.4 COM VEH 0 g! 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar Ut
Z E746075 IL 2025 REAR
TELEPHONE
IL D 0 1 G N FK16387J269189 Progressive ❑v ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same 988631478 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER
A/
m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑
/1 9 9 2 Jeep(after 196g)ind Cherokee 2003 00-NONE ,�_"i t2'-_, DUE TO CRASH 0 (� 2
0 Yr 13-UNDER CARRIAGE 10 l 2 FIRE El ® U2 C
c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Si 6 ....4 COM VEH D ® U1 CO
FIRST CONTACT 6 7A-�-"05 •It Yes,See Sidebar C
ELGIN IL 60120 0 1 0 BR90499 IL 2025 REAR
0 Si)
IL D 0 1J4GW48S33C607100 Unknown ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same Unknwon BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 4 05 /
3 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 /24 /2024 06 07 ®PM in a Work Zone? ®N DIRP co
1 t 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 99 / / ❑PM• 0 Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Cortes Marquez. Mauro 11-601-Ax S1530000155 / / ID PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
t 2 ❑ ARREST NAME AM
7 / / pM El Unknown work zone type 35
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 35
1530-Soto.Oscar 1 of / / ❑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 -<
/ INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Q / /, CD _ (example:shuttle or charter bus):or
I- I- --I----; cv '"' �'`�I } } } transporting employened to es hecoursee or fewer o their eers mplod yment example:employeerier X
// // (® transporter-usually a van type vehicle or passenger car):or w
C
i. 4. Is used or designated to transport between 9 and 15 passengers,including ((I)
}--- ----; - •} } } g po the driver,
Q for direct compensation(example:large van used for specific purpose):or
L i t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires '0
. placarding(example:placards will be displayed on the vehicle). ,Zmt
/ tiara—unit) CARRIER NAME Z
/ / ADDRESS D
/ / C)
CITY/STATE/ZIP g
/ - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
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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
Tan Silver
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE