HomeMy WebLinkAbout2024-00079785 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 HI I III 1111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo0a6727 6
u, 9 U2 1 1 1 u,99 uz U199 u2 U,99 U2 1 1 9 U1 1 U221 *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
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202412024-00079785 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ®Y 0 N 12 21 2024 DAM ❑YES ®NO U1 —<
PRESTON AVE Elgin02:32
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
0 !MI 0E S W KeepAve COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
® Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g)DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 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) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE it,. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
M 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN S 4 `Distraction Value ALGN
'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF il L 6 1i COM VEH 0 E! 1 O
I— FIRST CONTACT 99 7_;—, 5__ *IIYes.See Sidebar U1
0 1 0 UNKNOWN REAR
2 Z
_ TELEPHONE
IL Other UNKNOWN Unknown ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99
0 DRIVER I} PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 M/V 0 NCV 0 DV CIRCLE NUMBER(S) U1
yr Ford Ranger 2008 00-NONE N_' t2""_, DUE TO CRASH ❑ 21 1
J.) 13-UNDER CARRIAGE cti 2 FIRE 0 ElU2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 ❑ El SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 1 A 4 COM VEH ❑ El U1 toF,,, FIRST CONTACT 7 Q i' .s •It Yes.See Sidebar C
3324828B IL REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTYR10D48PA94789 Safeway Insurance ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Rivas Lechuga. Luis. B. 4150314-IL-PP-001 BAC
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
EV MOST EVNT LOS DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 12,21 ,2024 02 38 ®AM 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
2 0
28 18
N 3 0 0 CITATIONS ISSUED 0 PENDING / / 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
— u a, ARREST NAME / / 0 PM '
1 ® 0 Utility
1 1 1 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING SLMT
o AM
t 2 0 ARREST NAME 12)21 12024 02 54 ®PM 0 Unknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
476-Ramos.Clarissa 201 246-Kite , / ❑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
0 Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
1 -I
i- }---.r----; I } combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
�_---------i I
} } } transporting employee �In the course of their employment(example:employee
- transporter-usually a van type vehicle or passenger car):or co
}-----}----+ - I. } } } •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____.I I _ t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME -I
ADDRESS 0
V)
usxx. i. i. 4. C)
CITY/STATE/ZIP g
MOTOR CARR.ID El Interstate El Intrastate
Not To Scale 1 0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- 1 USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
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 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE