HomeMy WebLinkAbout2024-00075707 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 01101100 II M lI 1 fll II 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036 53492'
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00075707 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -11
® ❑ RELATED ❑Y ®N 12 01 2024 ❑AM ❑YES ®NO U1
DUNDEE AVE Elgin08:40
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
1 O !MI N E S W 190 HwyCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
® �C.'J O WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ®Y ❑ N PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
! ! FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Unknown.0. Nissan Altima 2013 00-NONE ,, • 12 0DUE TO CRASH 0VI E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 4 <
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 76-TOP 3 0 ' _
❑Y ®N ❑UNK VEH. ATCRASH 99-UNKNOWN `DistractionValue ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 i COM VEH 0 Ea 1 0
~ 0 9 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
Z R527484 IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
1 N4BL3APXDC156165 none ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Reyes.Celestino none 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
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N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑Nuy 0 NOV ❑Dv
!1 9 9 2 Honda Civic 2015 00-NONE „ " 12 M_, DUE TO CRASH ❑ 2 73
o Yr _ 13-UNDER CARRIAGE FIRE 0 El U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I ;,.4 COM VEH ❑ ® U1 co
FIRST CONTACT 8 O7 :_, _s •If Yes.See Sidebar C
East Dundee IL 60118 0 1 0 EY28178 IL 2025 REAR0 N
Z M
IL D 0 19XFB2F54FE033652 COUNTRY INS ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same P010380304 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12, 1/ l024 08 40 0 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
2 0 20 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING / / _ 0 PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
z
—a, ARREST NAME / / El PM
o N ® 11 1 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
35
t 2 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type U1
El
Cf T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
465-Dorado.Ariana 201 334-Fries , / ❑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.
el . IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
1
ADDITIONAL UNITS FORMS.
r ----r••--, , I I 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 -
' }---.r----; - combination):or —1
OR
INDICATE NORTH p1
1-.,' PO 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L f _ } (example:shuttle or charter bus):or
I . I I(_I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- L-------- } } } transporting employee in the course of their employment(example:employee
y a van type
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I �used ordrter- �llnatedto transport betweeicle or n9 and r15r) ssen rs,including[hedriver, to
1 I 1 ■ I T } for direct compensation(examp large van used for specific purpose):or O
in
L L.._-a , 190 - t . .. i. L 5. Is any vehicle used to transport anY hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
—1
— — CARRIER NAME Z
ADDRESS 0
ON
• + CITY/STATE/ZIP g
Not To Scale 1 MOTOR CARR.ID 0 Interstate 0 Intrastate 5
1 I r 1; I I 0 Not in Comm./Govt. Not in Comm./Other
_----- ..; - USDOT NO. ILCC NO. rn
XI
Source of above z
.
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?
❑ Yes II No ElUnknown 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
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
Black Gold
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE