HomeMy WebLinkAbout2024-00078557 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII OUI
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003661542'
u, 1 U21 1 1 2 U1 4 U2 1 u, 1 1_12 1 U, 1 U2 1 4 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2024I 2024-00078557 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED ❑Y ®N 12 15 2024 ®AM ❑YES ®NO U1
VILLA ST Elgin 03:34
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
15 !MI N E S W Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
® ® O Varsity WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES ❑MAV ❑ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 FOR DAMAGEDAREA(S) FIX)Ni TOWED U1 Q
NAME(LAST,FIRST,M) Gomez Avilez. Laura moo / !1 9 yr7 3 Ford Escape 2010 00-NONE 11 OI_, DUE TOCRASH ® ❑
13-UNDER CARRIAGE 10 , 2 FIRE 0
2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 2 4 0 Y ®SNEM❑ 15-OTHER
UNK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN 9 76•TIDP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;il 6 4 COM VEH 0 Ea 1 0
I .
Bloomingdale I L 60108 0 1 0 FIRST CONTACT 12 7_;L _5 *lives.See Sidebar U1
Z 9ES42938 IL 2025 REAR
TELEPHONE
IL D 1 FMCU9D77AKC14790 NIA ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same NIA 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ❑ N 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
2 0 0 3 General Motor�d;ET* 2015 00-NONE It-' 12--_, DUE TO CRASH ❑ C 2 73
o Yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistractJDn Value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1I 6 l,,_4 COM VEH ❑ ® Ut to
FIRST CONTACT 6 Y__{_O ._5 •IfYes.See Sidebar
n ELGIN IL 60123 0 1 0 EK38631 IL 2025 REAR
Z
IL D 2GKFLVEK7F6198430 American Family ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Nava Perez.Jesus 41047-13074-51 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (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
U 1 ® 11 1 12,15 l2024 03 34 ®❑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 C)
o"
2 ❑ 28 28 / / ❑PM, ❑Construction *
7
Z 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMSARRIVED TIME ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Gomez Avilez. Laura 11-601-Ax 1534000104 , ! El PM SLMT
I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N AM 30
T 2 ElARREST NAME Gomez Avilez. Laura 3-707 1534000103 , , 0 PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1534-Santiago.Jorge 302 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.
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 -<
, INDICATE NORTH
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or
11:
` , des a orfe erpasse ersan operated r I
3. Is gnetl to c rry 15 w ng tl by a contract carve O
�� IVOt TO SCale I. l- . transporting employees in the course of their employment(example:employee X
_..,_! o . ,_ I transporter-usually a van type vehicle or passenger car):or wL i... . ..l. J - } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or
L L____a____� v"' ` _ . i t 5. Is any vehicle used to transport anyhazardous material 'D
- I placarding(example:placards will be displayed on the vehicle). XI
—1
I CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP g
- i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate i<
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue,Light Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE