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HomeMy WebLinkAbout2024-00080527 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 III IIII IIIIIIIIi 11111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003672744 u, 1 U21 2 4 4 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 4 15 u1 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00080527 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n W HIGHLAND AVE Elgin11:28 ® ❑ RELATED ®Y 0 N 12 25 2024 12— ❑YES 0 NO U1 -< _ _ PRIVATE mo !day /yr ®PM FLOW CONDITION m FT!MI N E S W N JACKSON ST COUNTY PROPERTY ❑Y ® N DOORING ®y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT E Y ® N WITH VEHICLES INVLD El STOPPED U2 —I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST❑N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 UUV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q Guevara Ramirez.Claros. F. 1 0 ! yr © 13-UNDER CARRIAGE 16 i : 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 O m M 2 4 SYTM❑Y ®SNE DUNK VEH. O AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN - r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 I,.4 COM VEH 0 E! 3 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1 ZSWG2592 TX 2024 REAR TELEPHONE IL D SYFEPMAE9M P244793 American Alliance ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same ILAN005809400 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 X m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 row ❑I4DV 0 Dv 1 9 yf 2 Tesla Y 2023 00-NONE 1(j t2..-_, DUE TO CRASH p 2 73 o 13-UNDER CARRIAGE 16'1 c. 2 FIRE ❑ ElU2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 It,-4 COM VEH D ® U1 CO FIRST CONTACT 5 7 _,SOS •If Yes,See Sidebar ELGIN IL 60120 0 1 0 71886 EL IL 2025 REAR 0 Z IL 7SAYGDEE7PA079818 StateFarm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 0972538-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 El 11 4 12,25 /2024 11 28 ®PM in a Work Zone? NJ AM DIRP D co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 T 1 C) 0 2 ❑ 2 99 , , ❑PM• ❑Construction R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME Guevara Ramirez.Carlos. F. 11-901-A 1513000562 , ! ❑PM SLMT oN 1 ® 11 4 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility t 2 0 ARREST NAME Guevara Ramirez.Carlos. F. 6-303-A 1513000563 12125 ,2024 11 28 ®PM 0 Unknown work zone type U1 35 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 35 1513-Mann. Nathaniel 601 02 ,06,2025 01 30 ®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 r 0 - combing r more than pounds(example:truck or truckrtrarler 1. Has a weight rating10 000 i -< INDICATE NORTH tan)o p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ....._ _ } (example:shuttle or charter bus):or A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w i_ }-----}----l. - } } } •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 ' ' ___.i. W.?Chlcepo??St _ L } } i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt umrzz D ( _ R CARRIER NAME -I - Z _ _ ADDRESS i T. rn c) . CITY/STATE/ZIP g Not To Scale I - MOTOR CARR.ID 0 Interstate El Intrastate S.Jacks., St. O . I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other i- ------1 - USDOT NO. ILCC NO. rn 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 VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Blue Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE