HomeMy WebLinkAbout2024-00071905 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 111111 III 111111111�
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202412024-00071905 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 71
2475 ALFT LN Elgin03:00
® ❑ RELATED ❑Y ®N 11 12 2024 12— ❑YES El NO U1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
1 1 FOR DAMAGED AREA(S) FRO TOWED U1 O
NAME(LAST,FIRST,M) Alcedo. Bienvenido mo /
13-UNDER CARRIAGE } O FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m
M 2 SYTHER
4 ❑Y ®SNE DUNK VEH.M IN O AT CRASH ENGAGED O 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s :i1 B 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 12 Y __5 *II Yes.See Sidebar U1
Z Gilberts I L 60136 0 1 0 EA84081 I L 2025 r' ,
TELEPHONE
IL D 0 5NMS1 DAJ5PH629123 Geico ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire De Leos. Rosanne'. M. 6068792941 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
a DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIUV 0 KCV 0 DV
yr Hyundai Tucson 2022 00-NONE O1 Qj O DUE TO CRASH ❑ MI 1 a7
o 13-UNDER CARRIAGE I 1 FIRE 0 ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 ® SPDR C)
0 0
SYSTEM INENGAGED15-OTHER 9.19-TOP 3 9 0
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istracton Value
POINT OF s ) C u1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 �I•-5 CIO VEH
® c
CO
H ER73630 IL 2025 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
SNMJE3AE1 NH096651 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Mitvaben. Patel 982567044 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ❑ 18 2 City of Elgin Light Pole 11 /12 /2024 03 00 ®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)
2 IQ 18 1 150 DEXTER CT ELGIN IL 60120 28 99 11/12 /2024 03 01
®pM
, El Construction
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R 3 ❑ 1 8 1 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Alcedo. Bienvenido 11-601 1500000295 11/12/2024 03 05 Igi pM SLMT
j$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility
t 2 El ARREST NAME Alcedo. Bienvenido 3-707 1500000296 11/12 /2024 04 00 0 PM ❑Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 35
1500-Chew. Marie 901 12 / 16/2024 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 truckrtrailer -<
c ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
0 - (example:shuttle or charter bus):or
L L.___A.._.� r�oemsn.n� } 3. Isdesgnedto carry 15or fewer passengers and operated bya contract carrier I O
} } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
Alftnn L _Oa - I.
4. Is used or designated to transport between 9 and 15 passengers,including C-- } } } g po passen rs,includi the driver,
£ for direct compensation(example:large van used for specific purpose):or
cioL L___-a..... i �' �6 —` 'F\ L L 5 Is any vehicle any e used to transport hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle).
[ 1 ---
1 leri 1 1 11 1
L ,. .. ... .....
i \ CARRIER NAME Z
ADDRESS 0
C aucasatn . . . . D/)
CITY/STATE/ZIP ng
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i. --- '-4 - USDOT NO. ILCC NO. m
XI
Source of above z
'
IDOT PERMIT NO. WIDELOAD"; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Gray Gray
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE