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HomeMy WebLinkAbout2024-00078628 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III 11 III1II 10111 01100111110000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403671906 u, 1 U2 1 1 1 U1 4 U2 1 u, 1 1_12 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00078628 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m320 PRAIRIE ST El 03:08 ® ❑ RELATED ❑Y ®N 12 15 2024 12,— ❑YES IX]NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT/MI N E S W 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 Q83 DRIVER t] PARKED O DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROhrr TOWED U1 O Gomez. Ban.A. 1 2 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TDP 3 *Detraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i1_6 I, 4 COM VEH 0 Ea 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *IrYes.See Sidebar U1 Z 3707659B IL 2024 REAR TELEPHONE IL D 0 3GNEK12T64G223908 Erie El ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 1-1 99 9 Rodriguez. Evangeliza Q081118393 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 c 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 10 j t2 c 2 FIRE 0 ® U2 C o 13-UNDER CARRIAGE ', SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER 911,6•TOP3 0 ® SPDR n 0 Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ‘1;',..,) ii 4 COM VEH ❑ ® Ut CO F,,, FIRST CONTACT 7 B l'�.5 •If Yes,See Sidebar DU83-IS IL 2024 REAR0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T1 BF1 FKOFU961376 Geico ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 6120689077 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPONDER❑YN U1 = Y (UNIT) (SEAT) (DM (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 3 01 / / / UI 2 D:A / / 0 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 12,15 /2024 02 33 ®pm in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 Si 2 0 12 1 28 50 ! 1 ❑PM• 0 Construction * 1 N 3 0 'xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Gomez. Bryan.A. 3-413-F 1518000344 , ! El PM SLAT o N • ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 30 r 2 ARREST NAME AM 7 El ! ❑❑PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 3O 1518-Versetto. Elisa 301 246-Kite 01 ,21 ,2025 09 00 ❑PM Workers present? ®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 -< ` ` '' -' r INDICATE NORTH combination):or -I ' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C \ N _ (example:shuttle or charter bus):or C 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O \ - }} } transporting employee In the course of their employment(example:employee X -: , transporter-usually a van type vehicle or passenger car):or w __ \ Pik - } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C \ for direct compensation(example:large van used for specific purpose):or O L L____a____. wan r. _ L t 5 Is any vehdeused to transport any hazardous material(HAZMAT)that requires s urr`a _ placarding(example:placards will be displayed on the vehicle). XI \ t.+ t D CARRIER NAME —I \ _ ADDRESS 0 Not To Scale i \ CD/1 \ CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 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 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 No 0 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 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Gray 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: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE