HomeMy WebLinkAbout2024-00079101 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003671390
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202412024-00079101 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 12 18 2024 ®AM ❑YES ®NO U1 -<
PRESTON AVE Elgin05:34
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
E05 ®0 !MI N E S W Cooper Ave COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR El SLOW 2 fA
0 p Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N El FREE FLOW # LNS O
18:DRIVER p PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 9 /
yr
Chevrolet Malibu 2003 00-NONE 1 i,• 12 0OUE TO CRASH ❑ EN
13-UNDER CARRIAGE FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 2 m
M 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 I, 4 COM VEH 0 IE 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
Z EL15879 IL 2025 E
TELEPHONE
IL 1G1ND52J43M644054 None 0Y 0N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same None 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
0 DRIVER X. PARKED 0 DRIVERLESS 0 KO 0 PEDAL 0 EWES 0 row 0 NOV 0 Dv
yr -
o 13-UNDER CARRIAGE 10;i :., 2 FIRE ❑ El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
❑ -TOP 3 9 9 X
a Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraetlon Value
POINT OF S ) 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® C
F,,, FIRST CONTACT 7 O7 ,�=QI_5 •IfYes,SeeSidebar
2587407B IL 2022 aR 0 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1 GTV2NEC2GZ277514 PROGRESSIVE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Martinez. Raul. M. 971359695 BAC
$
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 U2Z
N 1 ® 18 1 12,18 ,2024 05 34 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 20 28 , r ❑PM ❑Construction *
1 G
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME Alexander. Brandon.o. 11-708 1546000045 , r El PM SLMT
o U 1 ® 1 1 1 CITATIONS ISSUED 0PENDING TIME ❑Utility
o NSECTION CITATION NO. ROAD CLEARANCE DI AM U 30
r 2 El ARREST NAME Alexander. Brandon.o. 3-707 1546000044 , r PM ❑Unknown work zone type 1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 El Am 1546-Ignacio. Patricia 201 391-Jacobucci 01 ,28,2025 01 30 El 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.
. O.
r ----r••--, , I : A CMV is defined as any motor vehicle used to transport passengers or property and: z
j [
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- `-----I-- --' I r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r r (example:shuttle or charter bus):or 0
- - - - N
C 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
L L____A____� , - y } transporting employeesinthecourseeoftheirem ment(example:employee X
� .. a , Not To Scale F } transppoortenrg-usll a van type vehicle or passenger car):or coMete
L L.___a____1I.
} } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or
It i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
i placarding(example:placards will be displayed on the vehicle). XI
m
iI
CARRIER NAME Z
l i ADDRESS
0
CITY/STATE/ZIP g
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I; I ❑ Not in Comm./Govt. Not in Comm./Other
_Y____; - USDOT NO. ILCC NO. rn
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. Xl
Xl
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Black
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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BYlT6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE