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HomeMy WebLinkAbout2024-00078667 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110 IIIII IIIII IIIII I II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003661583 u, 9 u21 3 4 2 Ut U2 1 U,99 1_12 1 1.11 99 U2 1 5 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00078667 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 SUMMIT ST Elgin08:40 ® ❑ RELATED ❑Y ®N 12 15 2024 DAM ❑YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W N LIBERTY ST COUNTY PROPERTY El ® N DOORING El #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRO r�TOWED U1 0 mo Unknown.0. Saturn ION 2006 00-NONE ©, >2 �/OUETOCRASH ❑ EN NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 F 1 4 SYSTEM IN O ENGAGED 0 15-OTHER 9 16.TOP 3 0 _ ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 ' .4 C.OM VEH 0 El 1 0 P.Z 0 9 CN24697 IL FIRST CONTACT 12 7 ; 5 *IfYes.See&debar U1 0 TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ 1G8AJ55F16Z189333 none ❑Y ®N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Rocha Estrada. Marcia) none 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 9 m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NCv 0 Dv CIRCLE NUMBER(S) U1 2 O 0 1 Toyota RAV4 2007 00-NONE 'o,� t2 c,�2 FIRE DUE o CRASH ® U2 2 C o 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0 POINT OF 8 i 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 6 O7 ,�=QIOS •It Yes.See Sidebar C St Charles IL 60174 0 1 0 CS55018 IL 2023aR0 Si) Z D IL D 0 JTMZD31V975070438 GEICO ❑Y 123 N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 6164741149 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPOND 0 N U1 = Y (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z N 1 ® 11 1 12,15 /2024 08 40 ®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 o" 2 28 18 ) ) 0 PM• ElConstruction * Z3 0 1!>I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 aD ® 11 1 ARREST NAME Cassata. Brianna. R. 3-414 465W-397 ) r El Pm SLMT o N • ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 35 r 2 ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 465-Dorado.Arians 201 — r ( ❑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 Has a weight rating more than 10,000 pounds(example:truck or truck/trailer 1 -I i- }----i-----1. Summit/St J I 0 - } combination):or -I Y INDICATE NORTH -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ♦ - } (example:shuttle or charter bus):or X < :- --:----1 transporting empined to oyees inthe course of 5 or fewer passengers er employment(example:employee a contract ner X �4' } r } transporter-usually a van type vehicle or passenger car): r w L -- - T -- 1 jI, - } } } g transport passengers,including the driver, C . ITT__�? �_•=--_>� 4. Is used or designated to trans rt between 9 and 15 —umc z unit 1 for direct compensation(example:large van used for specific purpose):or 0 L L--_-a-.... - t i. i IL 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). — — — — CARRIER NAME Z ADDRESS m1 I t Not To Scale j T. w 8 I CITY/STATE/ZIP g _ - i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other r ....Y._._1 - USDOT NO. ILCC NO. m 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. XI 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 M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Silver 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE