HomeMy WebLinkAbout2024-00076728 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 101101100 0 M 00 11 100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003€5117'
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00076728 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 12 06 2024 ®AM ❑YES ®NO U1 -<
E CHICAGO ST Elgin10:31
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
10 !MI N E S W Shales Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® O Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 Peoa_ 0 eaves 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 9 !
yr Q -
13-UNDER CARRIAGE 1a i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 4 <<Tl
M 2 SY4 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF $ ;iI 6 4 COM VEH 0 0 1 0
FIRST CONTACT 12 7. . _5 *If Yes.See Sidebar U1
Z Chicago IL 60609 0 1 0 EY11192 IL 2025 ,
TELEPHONE
IL D 0 KMHTC6ADOCU051273 American Alliance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA-1001905-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑IR,Iv 0 NOV ❑Dv
/1 9 8 2 Chevrolet Cruze 2016 00-NONE 11 12--_, DUE TO CRASH ❑ C 2
o _ 13-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
8 I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i
6 �'_ COM VEH 0 ® U1 CO
FIRST CONTACT 6 Y__{_O ._5 •If Yes.See Sidebar
Z Schaumburg IL 60193 0 1 0 Z750572 IL 2025 REAR 0 Si)
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IL C 0 1 G1 BE5SM2G7307073 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3038567-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 12,61 l024 10 31 ®❑AM 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 C)
0 2 ❑ 03 99 I ! 0 PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1El 11 1 ARREST NAME Giron-Galindez.Wilmer.A. 11-601 W1544000051 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM U, 35
r 2 0 ARREST NAME 12)6) 1024 10 33 0 PM ❑Unknown work zone type
-
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
1544 Solis•Yulissa 302 404 Duffy i , ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , 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 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
co
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 El 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
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LOCAL USE ONLY TRAILER VIN 2 m
v
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. w
Yellow Red
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 DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE