HomeMy WebLinkAbout2024-00076595 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a651206
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TWO/
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83 B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00076595 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN LIBERTY ST Elgin05:16
® ❑ RELATED ®Y 0 N 12 05 2024 ❑AM ❑YES N NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W KEEP AVE COUNTY PROPERTY ❑Y N N DOORING ❑y #OF MOTOR IR SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2/
yr
FOR DAMAGEDAREA(S) FROM�TOWED U1
Kia Motors Co 2014 rento 00-NONE 0 >2 �/DUE TOCRASH ® ❑
13-UNDER CARRIAGE 10 1 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 N U2 3 <<T1
M 2 4 ❑Y IN n 15-OTHER
SYSTEM
❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 4 COM VEH 0 N 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7 ; _6 *II Yes.See Sidebar U1
Z FA49621 IL 2024 REAR
TELEPHONE
UNK. D 0 5XYKT3A69EG441499 Ramos Insurance ❑Y IlN U2 • m
IE EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILS1065611-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Refused 0 Y N N 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMv 0 NCv ❑DV CIRCLE NUMBER(S) U1
2 0 0 1 Cadillac Escalade 2011 00-NONE 0. QI'-O DUE TO CRASH rg ❑ 2 x
...
Yr 13-UNDER CARRIAGE 10( I E FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 (3)-OTHER 9,16_TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistrag 9 0 lon Value U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH 0 N W
FIRST CONTACT 12 7�� __.6 •If Yes.See Sidebar
60110 0 1 0 EY44327 IL 2024 I 0 Si)
IL D 0 1 GYS4AEF2BR263664 State Farm ❑Y N N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1668716-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 12 r 05 r2024 05 16 ®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 �
0 2 0 28 24 ) / ❑PM 0 Construction *
N 3 ❑ N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Duran. Emerson.J. 6-101 485318 / r El PM SLMT
El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N AM 30
t 2 El ARREST NAME Duran. Emerson.J. 11-601-Ax 485317 r r a PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
485-Quintana.Josue 201 334-Fries 02 ,04/2025 09 00 ❑PM N 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.
.. .. , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r• -, II
tit 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
- }__-_r ---_ ; } combination):or —I
INDICATE NORTH p1
4. ` r?•' I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L J N Not To Scale = f i� 003i - (example:shuttle or charter bus):or 0
r 3. Is designed to carry15 or fewer` A g passengers and operated by a contract carrier I 0
Keep?Avel �— } } } transporting employees In the course of their employment(example:employee X
M.r r transporter-usually a van type vehicle or passenger car):or co
' ' _-_� I r - I. 4. Is used or designated to transport between 9 and 15 passengers,including y
-- - -_�,,� f_ - - } } } g po pafc p rs,):or the dryer,< • _a_
Event?l Unit 1 for direct compensation(example:large van used for specific purpose):or OD
t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
—0\ I I placarding(example:placards will be displayed on the vehicle). XI
I CARRIER NAME Z
ADDRESS 'n
w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I t I t t ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
I'---- ----4. - USDOT NO. ILCC NO. m
Xl
Source of above z
. 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 0 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 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE