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HomeMy WebLinkAbout2024-00079111 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII DVII1 11� III H1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00a6&6304 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U1 1 U2 1 1 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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 202412024-00079111 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m ® ❑ RELATED ®Y 0 N 12 18 2024 ®AM ❑YES ®NO U1 BENT ST Elgin06:58 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Q83 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 2 n 0 5 FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q NAME(LAST,FIRST,M) Medina Nicanor.Juan mo Unknown Unknown 00-NONE DUE TOCRASH ® ❑ ! ! yr 1t. 12 E 13-UNDER CARRIAGE 10l FIRE 0lE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 2 m SYSTEM IN ENGAGED 15-OTHER 916•TOP3 M 2 8 0 0 x ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 0 O `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF l 6 11 COM VEH 0 Ea 1 n REAR c Z ELGIN I L 60120 0 1 0 FIRST CONTACT 5 O7 _:�fall _OS *II Yes.See Sidebar U1 0 TELEPHONE IL C 0 Bristol West ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR 99 9 Prado.Selena G01-5269182-00 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 eu m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 I uv 0 NOV 0 DV !1 9 8 3 Chevrolet Silverado 2010' 00-NONE Q j Z p DUE TO CRASH ❑ 2 0 13-UNDERCARRIAGE 10j ©1( 2 FIRE 0 ® U2 C c il M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `(Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 1l, COM VEH ❑ ® U1 CO FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar = ELGIN IL 60120 0 1 0 3581295B IL 25 RFJ IL D 0 1 GCSKSE31AZ263998 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 972273634 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) 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,18 /2024 08 00 ®❑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 OT 2 ❑ 28 99 N 1 3 0 0 CITATIONS ISSUED 0 PENDING /• / _ ❑PM ❑Construction >E SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 —a, ARREST NAME / / ❑PM ' 1 ® 11 1 0 CITATIONS ISSUED PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ AM U, 30 t 2 El ARREST NAME 12)18 12024 07 45n PM ❑Unknown work zone type n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 468-Barron. Miguel 401 391-Jacobucci , / ❑❑PM Workers present? ®N U2 30 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. I q r ----r••--, , I A - ; 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.I INDICATE NORTH combination):or .Z-1 Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r (example:shuttle or charter bus):or 0 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I I- --I-- O IQ I. } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L ' _ s I �— 4. Is used or designated to transport between 9 and 15 passengers,including y-- ` - } } } g po passen rs,indudi the driver, I for direct compensation(example:large van used for specific purpose):or I. -a-___J alt_ ( i. < < L 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires u wool ,IB.nt7St) I placarding(example:placards will be any on the vehicle). m 1 It I CARRIER NAME Z ADDRESS 0 (St7tirsk.75f.] D I 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I I ❑ Not in Comm./Govt. Not in Comm./Other I. --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 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 Black Beige u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/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 ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE