HomeMy WebLinkAbout2024-00081406 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
101101100 0011111000
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X40a676400*
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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 ❑5501-51.500 El ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2024I 2024-00081406 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
® ❑ RELATED ®Y 0 N 12 30 2024 DAM D YES ®NO U1
HOPPS RD Elgin05:56
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W UMBDENSTOCK RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0
F T TOWED U1 O
FOR DAMAGEDAREA(S) FRO
Luna. Louie 0 8 /
yr 13-UNDER CARRIAGE �a 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m
M 2 8 ❑Y ®SNEM DUNK VEH. O AT CRASHIND O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4 COM VEH ❑ j$J 1 0
" �- GILBERTS IL 60136 0 1 0 FIRST CONTACT 12 7 ; _-5 *Il Yes.See Sidebar U1
Z3815216B IL 2025 E
TELEPHONE
IL D 0 1 GTRUCED4RZ372233 State Farm ❑Y J N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Quinones. Luz 2178626SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv 0 NOV ❑Dv
!1 9 9 5 Mitsubishi Lancer 2014 00-NONE „ 12..-_, DUE TO CRASH rg D 2
0 13-UNDER CARRIAGE o I 2 FIRE 0 ® U2 C
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i 6 1� 4 COM VEH ❑ ® U1 W
F,,, FIRST CONTACT 1 O Y�� , =5 •Iryes.See Sidebar C
ELGIN IL 60123 0 1 0 Q235463 IL I 0 Si)
IL 0 JA32U2FU4EU004408 Liberty Mutual ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same A0V24310333795 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
®N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 Comed COM ED electric box damage 12,30 /2024 05 56 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 1300 SPAULDING RD Elgin IL 60120 2 28 , , _ ❑PM ❑Construction >E
Z 3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Luna. Louie 11-901-A S1507000340 / ! El PM SLMT
1$! •CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NDI AM• ❑Utility
t 2 0 11 2 ARREST NAME Luna. Louie 11-601 S150700041 12130 /2024 06 58 ®PM El Unknown work zone type U1 30
2 2 3 ❑ 43 2 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑glvl Workers present? ❑Y 30
1507-Ruiz.Alondra 702 334-Fries 21 r 11 /025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' I. INDICATE NORTH combination):or .Z-1
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 T,
t4 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
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} } } transporting employees in the course of their employment(example:employee
Not To Scale transporter-usually a van type vehicle or passenger car):or w
I I. } } } 4. Is used or designated to transport between9and15passengers,includingthedriver. N
,,,,,,w � � � � for direct compensation(example:large van used for specific purpose):or
L L-- ...... � ��' �� - t i. I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
— placarding(example:placards will be displayed on the vehicle). XI
...........
-
CARRIER NAME —I
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r r -1- 1 I r i. i. i... ADDRESS 0
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CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I""Y""- USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
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LOCAL USE ONLY TRAILER VIN 2 m
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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. Z
Black Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE