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HomeMy WebLinkAbout2024-00080643 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets _ Mil III 0 IftIl DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV u, U2 1 1 2 U1 U2 U1 1_12 U, 1 U2 1 5 9 U121 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 10 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00080643 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n 248 MICHIGAN ST El ❑In RELATED ❑Y ®N 12 26 2024 05:49 ❑AM ®YES 0 NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR '0 SLOW 1 U) ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 0 DRIVER N PARKED 0 DRIVERLESS 0 FED O PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) 13-UNDER CARRIAGE 10 i , 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 rrn SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 ' _ ❑Y (Z)N ID UNK VEH. AT CRASH 99-UNKNOWN 6 4 `Distraction Value ALGN CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F RST OF 12 7_!{Ot__5 ClrrYes.SeeSidebar❑ !3 U1 1 0 Z DE72819 IL 2025 LIB TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 5N1AT2MV6HC789130 Magnum ®Y ❑N U2 r in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Mc Govern.Joseph. M. ILP3368676 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r RESPONDER ( 0 5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EDUCE 0 NMv 0 NCv 0 DV CIRCLE NUMBER(S) U1 yr ©2,, C Ti 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 X a NJ ❑❑Y N UNK VEH. AT CRASH 99-UNKNOWN POINT OF A `Oistraci n Value 6 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 6 1':s CIOMfVEHYes.See Sidebar ® titC ~ CG49077 IL 2024 REAR 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O 1 G N EK13Z52J316689 Freeway Insurance ❑Y ®N RDEF XJ EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Cervantes. Luis.G. ILP3398661 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 LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12!26 /2024 05 49 ®AM in a Work Zone? ®N DIRP co r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T 0 N 1 3 0 ❑CITATIONS ISSUED 0 PENDING / / _ ❑PM- 0 Maintenance lotion SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1 z —a, ARREST NAME / / ❑PM o N ® 11 1 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 25 r 2 0 ARREST NAME AM T ! r ❑❑PM ❑Unknown work zone type U1 n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1 530-Soto.Oscar 401 02 !04,2025 09 00 0 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. 0 A CMV is defined as for vehxae used to tra and: r ----,5-••--, ; any mo nsport passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer 3. • i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I X1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' J. , } (example:shuttle or charter bus):or X 3. Is . L.___A.. 1 i. <--_... . J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } • � . transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , < .---_-a-___� , J. , , 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 0 L L___-a____.l L L L ...._-..i._ 1 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). m,Zt --I CARRIER NAME Z i. ADDRESS 0 th CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . GVWR/GCWR m ❑ <10,0oo 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI 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 73 IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIM 1 m to 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 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Maroon u 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE