HomeMy WebLinkAbout2024-00081051 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ® 6 Injury and for Tow Due To Crash YR 202412024-00081051 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r7
® ❑ RELATED PRIVATE ❑Y ®N 12 28 2024 DAM ❑YES IX]NO U1 -<
S MCLEAN BLVD Elgin mo /day/yr 11.48 ®PM FLOW CONDITION M
On ®!MI N E S ® West Mclean Ave COUNTY PROPERTY ®Y ❑N DOORING El #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 4 /
yr Jeep(after 19680nd Cherokee 2012 00-NONE 0• O-0 DUE TO CRASH ® 0
13-UNDER CARRIAGE D) !. 2 FIRE 0 (E C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED ❑ 0U2 M
M 2 8 ❑Y SYSTEM
❑UNK VEH. 0 ATCRASHD 0 99-OTHERWN 9 B TOPO `DistractionVatuc 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D i s 'I COM VEH 0 j$J 1 n
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 O7 _:�Q-OS *If Yes.See Sidebar Ut 0
0
Z EV34466 IL 2012 REAR
TELEPHONE
OTH Other 1 C4RJ FDJ 1 CC152057 NIA ❑Y ®N U2 ni
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NIA 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 ou
0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 Dv
yr 12 _ 71
.0 13-UNDER CARRIAGE 10 I 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 3
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='.,:=5 CIfO e1sVSee Sidebar❑ ❑ C
CO
F` pEAR` C
Cin
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 Z
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
W 09 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 43 3 12!28 /2024 11 48 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 28 08
! / 0 PM- ❑Construction *
t
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
-a, ARREST NAME Veliz Lizard°.Jose. L. 11-502.15- 752515 / / 0 PM SLMT
o u 1 0 0 CITATIONS ISSUED I!�PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N AM• ❑Utility
o t 2 El ARREST NAME Veliz Lizard°.Jose. L. 6-101 752516 12/29 /2024 01 10 [M PM El Unknown work zone type U1 15
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1513-Mann. Nathaniel 602 01 /29/2025 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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
0 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -
c ` '' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
s 3. Is designed to car 15 or fewer passengers and operated a contract carrier
I- }----A----'
rwcoaear.a�w } } } transporting employees In the course of their employment(example:employee
s. � transporter-usually a van type vehicle or passenger car):or CO
L I } 4. Is used or designated to transport between 9 and 15 passengers,including C---- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
L L____a____� ,,,,,y„d,�,r,� r I L _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
• placarding(example:placards will be displayed on the vehicle). XI
4,4 (. CARRIER NAME Z
r9 1 O
ADDRESS
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I Not 7b soots I ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
----- ----1 USDOT NO. ILCC NO. m
XI
Source of above z
. 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 VIN 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE