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HomeMy WebLinkAbout2024-00080080 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M 11111111 1101111110T101110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a6 26 2 u, 1 U2 1 1 1 U1 8 U2 u, 1 U2 U, 1 U2 5 8 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El 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/or Tow Due To Crash El AMENDED YR 202412024-00080080 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 .-1 ® ❑ RELATED PRIVATE ❑Y ®N 12 23 2024 ®AM ❑YES ®NO U1 -< BIG TIMBER RD Elgin mo /day/yr 01 38 ❑PM FLOW CONDITION m 02540!MI N E S O MADELI N E Ln COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 -I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FRONT_ TOWED U1 0 Garcia. Ruben. M. 0 1 / yr 13-UNDER CARRIAGE 10. 2 FIRE ❑ alC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 0-TOTAL(ALL) DISTRACTED ® 0 U2 m M 2 8 ❑Y ®N SYSTEM ❑UNK VEH. AT CRASHD 99-UNKNOWN 9©TOP 3 `Distraction Value 7 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 El 1 00 ~ Lakewood I L 60014 B 1 0 FIRST CONTACT 12 7_: __5 *lI Ves.See Sidebar Ut Z E819831 IL 2025 REAR TELEPHONE IL D 0 1 G1 PASSHOF7192024 Geico ❑Y ❑N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same Unknown 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y 23N 2 rg- ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV yr 12 _ 71 .0 13-UNDER CARRIAGE 10 1 c. 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 0 Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT YA='+:- C•IO e1s.EH See •Sidebar❑ 0 C CO F` REAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPNDER❑YD❑N U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 1 2 12/23 /2024 01 38 ®❑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 v t 2 ❑ 9 20 05 12/23 /2024 01 39 ❑PM ❑Construction * R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ®AM ❑Maintenance U2 -a, ARREST NAME Garcia. Ruben. M. 3-707 1510000554 12/23/2024 01 44 ❑pM SLMT o u 1 ❑ igI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility r 2 0 ARREST NAME Garcia. Ruben. M. 11-709-A 1510000553 12/23 /2024 02 28 MPM 0 Unknown work zone type U1 45 n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 1510-Cortes. Reyna 901 01 /28/2025 09 00 ❑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 -< i- }--_.r-_--; i 4.4.41.1 } INDICATE NORTH comb nation'or p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ Not7b8- ' - } (example:shuttle or charter bus):or tai A �-ID 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L __ ma""" - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z ADDRESS 0 V) 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other USDOT NO. ILCC NO. m XI Source of above 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue,Dark u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE