HomeMy WebLinkAbout2024-00076084 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil l III H IIIl Milil O l l IDD 11111D
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003648076
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ 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$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2024I 2024-00076084 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
MASON RD Elgin03:16
® ❑ RELATED ®Y 0 N 12 03 2024 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W ALFT LN COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Ocam o Bahena. Lazaro 1 2 /
yr 13-UNDER CARRIAGE FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 0 m
M 2 4 El ®NNE❑ IN ENGAGED 15-UNK VEH. O AT CRASH O 99-UUNKNOWN 016 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D;i�6 �'.4 COM VEH 0 j$J 1 0
~ Palatine I L 60074 C 1 0 FIRST CONTACT 9 7 : __5 *irYes.See&debar U1
Z EG69382 IL 2025 REAR
TELEPHONE
IL D 2G4WD54L1 M1864402 KEMPER ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire OCAMPO-HERNANDEZ. MARTHA 12AU001575500 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NAV 0 Ncv 0 DV
!1 9 y 73 Hyundai Sonata 2011 00-NONE O-i Q!'-O DUE TO CRASH p 2 x
o 13-UNDER CARRIAGE 10) 12 FIRE 0 ® U2 C
F 2 5 SYSTEM IN 0 ENGAGED 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
8 i1i 4 COM VEH
FIRST CONTACT 1 2 7 B .5 •If Yes.See Sidebar❑ ®
n LAKE IN THE HILLS Z I L 60156 C 1 0 Z216209 I L 2025 REAR
C
IL D 5NPEC4AC1 BH295919 UNAVAILABLE ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same UNAVAILABLE BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 03 / F 2 5 B 1 0
m
/ / #OCCS >
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 12,03 l2024 03 10 ®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)
v 2 0 2 99 12,03 ,2024 03 17 ®pM ❑Construction >E
R 3 o zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
-a, ARREST NAME Ocampo-Bahena. Lazaro 11-901-A 752471 12,03/2024 03 25 Igi pM SLMT
o U 1 ® 11 4 CITATIONS ISSUED 0 PENDING
o NSECTION CITATION NO. ROAD CLEARANCE TIME AM, ❑Utility
t 2 El ARREST NAME Ocampo-Bahena. Lazaro 6-303-A 752469 12/03 /2024 04 36 ®PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1533-Ruiz.Jose 901 223-Hughes 01 , 14,2025 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 truck trailer -<
c ` -- -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I - } (example:shuttle or charter bus):or X
Not To Scale 3. Is designed
L L A I0esg to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees in the course of their employment(example:employee
l I transporter-usually a van type vehicle or passenger car):or w
L L.___a__ \ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L L____a____. .le, {F�� i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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CI ' i placarding(example:placards will be displayed on the vehicle). XI
m
w.eerms. - CARRIER NAME Z
ADDRESS 0
w
"""" CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"---- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes 0 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' M
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Maroon White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE