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HomeMy WebLinkAbout2024-00080196 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 000 lI 00 IOU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo0a678345 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* 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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202412024-00080196 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl ® ❑ RELATED PRIVATE ❑Y ®N 12 23 2024 ❑AM ❑YES ®NO U1 S LIBERTY ST Elgin mo /day/yr 03:41 ®PM FLOW CONDITION III _ 15(� COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 cn ® �C.7/MI O E S W Laurel St WITH VEHICLES INVLD 0 STOPPED U2 --I ElAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 tg:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 NT TOWED U1 Gomez. Marcos Dodge Neon 2005 00-NONE ©, O"�DUE TOCRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 10. r11 M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH 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 a 4 COM VEH 0 Ea 2 O ELGIN I L 60120 0 1 FIRST CONTACT 12 7 ; __5 *II Yes.See Sidebar U1 Z EL32042 IL 2025 E TELEPHONE IL D 0 1 B3AS66S25D286834 AMERICAN ALLIANCE ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Gonzalez Carillo.Jessica ILAA087562000 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 .40 g DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑ ivy 0 NOV ❑DV CIRCLE NUMBER(S) U1 /2 0 0 6 Ford Mustang 2004 00-NONE 1("i ,z -_, DUE TO CRASH ❑ (� 2 0 13-UNDER CARRIAGE 10'1 2 FIRE ❑ ® U2 C c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S .i. COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,�=Q)OS C.)ryes.See Sidebar C ELGIN IL 60120 B 1 EC11788 IL 2025 i Si)0 IL D 0 1FAFP40644F151319 STATE FARM INS ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 3357778SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 1 2 / F 2 4 B 1 m S / / #OCC D / / U1 1 D / / 2 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 12,23 /2024 03 41 ®FM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 28 03 ! / ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 - U2 a, ARREST NAME Gomez. Marcos 11-601 465-398 / / ❑❑PM• ❑Maintenance SL o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility MT 30 t 2 0 ARREST NAME AM 7 1 / ❑❑PM El Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 465-Dorado.Ariana 301 01 ,21 /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 ISt.!NVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , I ; A CMV is defined as any motor vehicle used transport passengers or property and: Y Hasatan weight rating more than 10,000 pounds(example:truck or truck trailer 1. .: 0 r }-___y__-_1 1 -< isi INDICATE NORTH oi BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r _ } (example:shuttle or charter bus):or i i X iii. 3. Isdesigned tocarry 15 or fewer passengers and operated a contract carrier I 0 pa g pe by } } } transporting employees In the course of their employment(example:employee X I transporter-usually a van type vehicle or passenger car):or C E /J } 1" •4. Is used or designated to transport between 9 and 15 passengers,including the driver, w for direct compensation(example:large van used for specific purpose):or O L L____a____i _ L i < . 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI -- 1 CARRIER NAME Z ADDRESS 0 Lunn* W CITY/STATE/ZIPg Not To Scale I MOTOR CARR.ID ❑ sta ❑ O I I T I I I ❑ InterNot in Cotemm./GaA. Not inIntrastate Comm.lOther ❑ o ;____Y____, 1 I USDOT NO. ILCC NO. m XI Source of above 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 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 Xl IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No 2 TRAILER VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Red Blue 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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE