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HomeMy WebLinkAbout2024-00078485 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets Mill III 11 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY u, 1 U21 1 1 10 U, 4 U2 1 u, 1 1_12 1 U, 1 U2 1 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202412024-00078485 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n ® ❑ RELATED PRIVATE ❑Y ®N 12 14 202412,— ❑YES ®NO U1 —< S BELMONT ST Elgin mo /day/yr 06:22 ®PM FLOW CONDITION m _ �r, COUNTY PROPERTY 0 Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n 235 ®!MI N E S ® Erie St WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED El DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 TOWED U1 FOR DAMAGEDAREA(S) R2'O 1T O Vega. Miguel.A. 1 1 / yr 13-UNDER CARRIAGE ©,I 0.,: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 m M 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 4 COM VEH ❑ Ea 5 0 F• Elgin I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1 Z 9 BN47906 IL 2025 REAR TELEPHONE IL D 1 FAFP52UXXG237685 Allstate Ins Co ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 975363342 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 I V 0 DV yr Honda Civic 2007 00-NONE „ 12 _, DUE TO CRASH ❑ 0 2 �7 o 13-UNDER CARRIAGE FIRE 0 ® U2 c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR 0 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 - POINT OF s I 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® CO F„ FIRST CONTACT 11 7 _, _5 •(ryes.See Sidebar DH90811 IL 2025 RFJ 0Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O 2HGFG12637H535988 State Farm Ins Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Camacho.Victor 136149N73 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = {UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 12,14 /2024 06 22 ®AM in a Work Zone? NJ oIRP co I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T 2 0 ! 1 ❑PM• El Construction * Z3 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 —a, ARREST NAME / / ID PM ' o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 30 t 2 0 ARREST NAME AM T 1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 3 0 ❑AM Workers present? D Y 30 481-Rodriguez. Hannah 602 334-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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. 0 A CMV is defined as for vehxae used to tra and: r ----,5-••--, ; any mo nsport passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - } }-- -;-- --; } } } r -, , ; ; , 1, ( combination):or —I INDICATE NORTH X1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' J. , } (example:shuttle or charter bus):or X 3. Is . L.___A_. 1 i. <--_... . J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , < .---_-a-___� , J. , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.I L L L ...._-..i._ 1 L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z i. ADDRESS 0 th CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m 73 Source of above z ) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m Z GVWR/GCWR 1 El <10,000 0 10,000-26,000 0 >26,000 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. P3 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 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 73 IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIM 1 m to 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 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Gray u 3 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 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE