HomeMy WebLinkAbout2024-00079476 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
IIIIII 00110000 0010011110*
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XoOa6:2814-
u, 1 U21 1 1 3 U116 U2 1 u, 1 u2 1 u, 1 u2 1 5 6 u, 1 U225 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 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 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2024I 2024-00079476 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED ❑Y ®N 12 20 2024 ®AM ❑YES ®NO U1 —<
VILLA ST Elgin04:11
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W G EORG E ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
IgI AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROf4r TOWED U1 Q
Cruz.Yasmine 0 1 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 2 m
F 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN O is-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i COM VEH 0 Ea 1 0
H F• Elgin I L 60164 0 1 0 FIRST CONTACT 11 7_: __5 *UYes.see Sidebar U1
Z 9 EB13910 IL 2025 REAR
TELEPHONE
IL D 0 JTMG1 RFV1 LD050082 Progressive ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same 986799247 3 m
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER eV
Refused ❑Y El 2 0
rg-
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAv Lil NCv 0 Dv
yr Nissan Sentra 2004 00-NONE „ '12' _, DUE TO CRASH 0 ® 1 77
Ja - 13-UNDER CARRIAGE FIRE 0 El U2
c
SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
❑Y El N 0 UNK VEH. AT CRASH 99-UNKNOWN ''OistrartIonValue 0
POINT OF s I 4 COM VEH ❑ ® ill CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT 1 O Y di =5 *Iryes,See Sidebar C
— Elgin IL 60120 BH14248 IL 2025 REAR 0Si)
3N1 CB51 D64L833948 First Chicago Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ILS104583500 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESPOND❑YElN Ui =
Y
;UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ❑ 1 2 COM ED ComEd pole#242J5 12,20 ,2024 04 11 ®❑Pmm� in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 ,,
2 ® 43 2 31 W710 SPAULDING RD Elgin IL 60120 11 28 12,20 ,2024 04 18 ❑pM
• ❑Construction 4 >F
R 3 0 El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME
J ®AM ❑Maintenance U2
a u 1 ® 43 3 ARREST NAME Cruz,Yasmine 11-601 W1512451 12,20,2024 04 38 ❑pM SLMT
o N 0 CITATIONS ISSUED • ❑
PENDING SECTION CITATION NO. ROAD CLEARANCE TIME Utility
aNA
AM U1 30
r 2 El ARREST NAME 1 2+20 ,2024 07 42n PM ❑Unknown work zone type
Cf n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1512-Juarez-Huichapan.Juan 400 , , ❑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 truckrtrailer -<
} }---_r__--; tY combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale 1 _ (example:shuttle or charter bus):or
X
. A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
L -----------; � � M>YaTBt' - 1 } } •
transporter Is nosed or des gnated to transport betweelly a van type vehicle or n 9 and r 1 passengers,including the dryer, C
for direct compensation(example:large van used fors specific purpose):or
.D
' Uri 1� t } } t 5. Is an vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
t
�- CARRIER NAME Z
ADDRESS 'n
fl
1 _ C
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other 00
‘I. - --1 - USDOT NO. ILCC NO. <m
XI
Source of above z
'
. Form Number
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Maroon
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE