HomeMy WebLinkAbout2024-00078204 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
IIIIII
Hill 0111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003675568
u, 1 U2 3 4 1 U1 2 U2 U, 1 1_12 U, 1 U2 1 1 U1 4 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202412024-00078204 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S STATE ST El In01:22
® ❑ RELATED ®Y 0 N 12 13 2024 ❑AM ❑YES ®NO U1 —<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W NATIONAL ST 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
Q83 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 00 0
0 9 !
yr
Rodriguez. Reynel Honda Odyssey 2004 00-NONE „ O i" i DUE TO CRASH ❑ EN
13-UNDER CARRIAGE 16 I 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 00 r rl<
M 2 SY4 ❑Y ONM DUNK VEH. 0 AT CRASH IN D 0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s :il 6 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_; _5 *Irves.See Sidebar U1
Z DN13106 IL 2025 Ismi
TELEPHONE
IL D 5FNRL18814B147305 Kemper El ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 51 2 Same 12AU001471249 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
Refused ❑Y El 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS El PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr 00-NONE .1.,-1 Qr-_, DUE TO CRASH 0 ❑ XI
0 13-UNDER CARRIAGE 10( I FIRE 0 0 U2 C
c
F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH 0 0 U1 CO
FIRST CONTACT 12 7�REAR_.5 •If Yes.See Sidebar C
I- ELGIN
0)n IL 60120 K
❑Y ❑N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Elgin Fire 1 52 2 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPOND
❑N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 4 12,13 l2024 01 22 ®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 �
;, 2 ❑ 12 4 2 28
! 1 El PM• ❑Construction
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
au 1 ® 11 4 ARREST NAME Rodriguez. Reynel 11-1008 1506-311 / ! El PM SLMT
o N •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE El Utility
30
TIME
r 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1506-Nunez. Maria 701 275-Engelke 01 , 14/2025 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••--, , N - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Cl) N) 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<1.
i- }-- _;-- --; I nation)or
Z INDICATE NORTH p0
0C
I Not 7b Scale _ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
r r r (example:shuttle or charter bus):or
Q 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0
es pa g pe
} } } transporting employees in the course of their employment(example:employee I °
11 I transporter-usually a van type vehicle or passenger car):or w
L L____a____i I 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I 01 t } } for direct compensation(example:large van used for speific purose):or
L L____a____� i —a _ I. i � 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
_ _ _ O
C ;�
m
placarding(example:placards will be displayed on the vehicle). ;p
1 +r D
STATE?ST ...
CARRIER NAME Z
�UNIT1 - ' ' ' ' __ 1 ADDRESS 'n
T.
CITY/STATE/ZIP 0
_ MOTOR CARR.ID 0 Interstate El Intrastate
I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
----------1 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE