HomeMy WebLinkAbout2024-00080932 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Dt 2 Sheets II III H IM OUI 011001fl1DI� 1�1OOHHIODD
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202412024-00080932 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
PAGE AVE Elgin 10:19
® ❑ RELATED ❑Y ®N 12 28 2024 ®AM ❑YES ®NO U1 -<
g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
0 !MI N E SLiberty St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® ® Liberty Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 FOR DAMAGEDAREA(S) FIX)Ni TOWED U1 Q
NAME(LAST,FIRST,M) Sanchez.Jaime mo 0 /
13-UNDER CARRIAGE 10 i ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 15-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL 6 4 COM VEH 0 j$J 1 0
F. FIRST CONTACT 12 7_:—, _5 *Irves.See Sidebar U1
... Geneva IL 60134 0 1 0 EB39991 IL 2025 REAR
TELEPHONE
IL D 0 2G NALDEK1D6112758 Unique ❑Y ign4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILP3378669 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 KCV 0 Dv
Yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16•TOP
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❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I 6 . . If
VEH ❑ ® ut CO
FIRST CONTACT 6 7A- -',_5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 DBR737 IN 2025 REAR 0 .C.
OTH Other 0 JTDBL40E799043116 United Equitable 0 Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Marquez.Jorge PPQ6008588 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 co
12,28 ,2024 10 19 ®❑PM AM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 �
v 2 03 99 12,28 ,2024 10 22 ❑PM ❑Construction >F
R O 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ®AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Sanchez.Jaime 11-710-A S1522-221 12,28,2024 10 25 ❑PM SLMT
o N ISI •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM 15
t 2 ElARREST NAME Ospino Ortega.Carlos.J. 6-101-A S1522-220 , , 0 PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 15
1522-Velazquez. Noeli 201 275-Engelke 01 , 13,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --1 -' r INDICATE NORTH combination):or
[.. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
® _ (example:shuttle or charter bus):or
r r r
L L 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
��4Aw transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } • •
for direct compensation(example::large van used for speific purpoe):or
the driver.
` ;----_i_----; s - i aqulrrei - } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
8 k placarding(example:placards will be displayed on the vehicle). ;p
FM-WM-
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CARRIER NAME Z
ADDRESS 0
T.
No!To Scale I co
C)
CITY/STATE/ZIP g
- MOTOR CARR.ID 0 Interstate ❑ Intrastate 5
I I T ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------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 ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No :
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
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. Z
Silver White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE