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HomeMy WebLinkAbout2024-00078677 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H II II IIIIII 01100 IIII IflU II ill III I01111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4036615 u, 1 u21 3 4 4 u, 3 u216 u, 1 U2 1 u1 1 U2 1 5 15 u1 1 u2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202412024-00078677 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED ®Y 0 N 12 15 2024 ❑AM ❑YES ®NO U1 -< N STATE ST Elgin10:31 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W W H I G H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ® STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 O NAME(LAST,FIRST,M) mo !1 9 8 8 Toyota Tundra 2003 00-NONE „ t2 , DUE TO CRASH ❑ EN 13-UNDER CARRIAGE �. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m 101 F 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 9 16•TOP® `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 ii,4 COM VEH 0 j$J 1 0 F. FIRST CONTACT 3 7_;—_;__5 *lives.See Sidebar U1 Z Carpentersville IL 60110 0 1 0 3515078B IL 2025 REAR TELEPHONE IL D 0 5TBBT441735374559 American Heartland ❑v IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 99 Huesca Sanchez. Maria AHQ0036974 2 m "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCV 0 Dv CIRCLE NUMBER(S) U1 !1 9 9 7 BMW M3 2021 00-NONE O", Q!'-O, DUE TO CRASH 0 ❑ 2 x o ©-UNDER CARRIAGE 10( I E FIRE ❑ ® U2 C c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH D ® U1 CO H FIRST CONTACT 12 7. •If Yes.See Sidebar ELGIN IL 60123 0 1 0 ES16457 IL 2025 REAR M IL D 0 WBA13AL05M7G96347 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 Same 1330614-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) / 01 O 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 l2024 10 31 ®PM 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 0 2 25 99 1 1 ❑PM ❑Construction * R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Najar Salas. Maria.C. 11-601 S1521-000383 / ! El Pm SLMT I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility o t 2 El ARREST NAME Najar Salas. Maria.C. 11-306 S1521-000382 12)15 /2024 11 11 N ®PM El Unknown work zone type U1• 30 2 2 3 ❑10 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1521-Vega.Wendy 601 11 , 41 ,025 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 truck trailer -< i- ----_r_-_-; _ INDICATE NORTH combination):or p3 t BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or n 1J11 'iIL.. Not To Scale 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O -_.-I- _ } } } transporting employees In the course of their employment(example:employee X m transporter-usually a van type vehicle or passenger car):or L L.___a____.l ~ = t t4i } } } 4. Is used or designated to transport between9and15passengers,includingthedriver. N J..u�_r• for direct compensation(example:large van used for specific purpose):or i H uKa_ _ O 71 i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a ~ placarding(example:placards will be isplayed on the vehicle). r - - m XI t , "" , CARRIER NAME Z ADDRESS 0 D 1 1Itlif i. i. i. i. 4.i. i. i. i. 4. CITY/STATE/ZIP w I I MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. -- - - USDOT NO. ILCC NO. m XI Source of above z . -I 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 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 ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes iO No El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No - 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 Red White 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE