HomeMy WebLinkAbout2024-00076149 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X60365349,i
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202412024-00076149 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 rl
S MCLEAN BLVD Elgin 07:35
® ❑ RELATED ®Y 0 N 12 03 2024 ❑AM ❑YES ®No u1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION MFT/MI N E S W LI LLIAN ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O 0
TOWED U1 Q
NAME(LAST,FIRST,M) mo yr
Ramirez Guillen. Isabella Toyota Highlander 2013 00-NONE 0O �i�DUE TOCRASH ® ❑
13-UNDER CARRIAGE I • FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ]$I U2 0 171
F 2 8 ❑Y ®SYSNEM❑UNK VEH. O ATCRASHH D 0 99-UUTHER NKNOWN 9 16•TOP�3 `DistractionVatuc ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 6 jl COM VEH ❑ 0 1 C)
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7-_ _O =II Yes.See SidaDar Ut 0
Z BT62648 IL 2025 MAR
TELEPHONE
IL D 0 5TDZA3EH7DS043841 STATE FARM INS ❑Y ®N U2 1--
IF. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Ramirez.Juan 0901410SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 .40
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 to,ty 0 txv 0 Dv
'1 9 y 1 Dodge Dakota 2003 00-NONE O QI-O DUE TO CRASH 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COMVEH ❑ ® U1 CO
FIRST CONTACT 12 7�_,--- •If Yes.See Sidebar
= ELGIN IL 60123 B 1 0 3542457B IL 2025
IL D 0 1 D7HG48X13S228823 American Alliance ®Y ❑N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Mendez. Luis.S. ILAA099681500 BAc $
HOSPITAL(TAKEN TO) INCIDENT RESPONDER IF'Y' OWNER STREET,CITY,STATE,ZIP 996 ARefused ❑Y ®N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 12 / F 2 8 B 1 0
m
/ / #OCCS D
/ / UI 2 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 El 11 4 12,03 ,2024 07 35 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
T
o",
2 0 2 28 ( , 0 PM• ❑Construction
N 1 3 0gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME Ramirez Guillen. Isabella 11-901-A 465-395 , r ❑PM SLMT
o u 1 ® 11 4 MI CITATIONS ISSUED 0 PENDINGTIME ' ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 35
r 2 El ARREST NAME Rivera. Hector 6-101* 465-396 , / pM Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? ❑Y 35
465-Doracio.Ariana 602 334-Fries 01 ,21 ,2025 01 30 ®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.
. -1--
•--, 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 -<
` `__ -'-___-' I I 1. INDICATE NORTH �mbnatbn)or
I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I Li ® - } (example:shuttle or charter bus):or 0
-__--1---_-� I °'' IH
Nat so seek ' 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
P } } } transporting employees in the course of their employment(example:employee X
y a van type
i. ...l. ' fi I transporter sedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,including[hedriver, to
} } for direct compensation(examp large van used for specific purpose):or O
N l...1 L Ppi ,- i I ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 < « < ]
Aft._ . placarding(example:placards will be displayed on the vehicle).
_ CARRIER NAME Z
Lien swot
I I ADDRESS D
I I w
8.Mair Berv1 I I ' CITY/STATE/ZIP n
tw
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MOTOR CARR.ID 0 Interstate 0 Intrastate
I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
1- --- --4 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. 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
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Silver Gold
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 ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE