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HomeMy WebLinkAbout2024-00081628 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111 III 11 III1II IIIIII 01100 HO I 11111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003f82781 u, 1 U21 1 1 2 U, 7 U2 1 U, 1 u2 1 U, 1 U2 1 4 11 U1 1 U2 1 *P 0 1 1 9* 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-S1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 2024I 2024-00081628 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 12 31 2024 ❑AM ❑YES ®NO U1 NATIONAL ST Elgin03:50 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m ®!MI N E S W Times COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn Sq 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 (g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FTtOmr TOWED U1 0Tenelema Allaico. Fred V. Chevrolet Malibu 2013 00-NONE , • 2 , DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) y- mo yr 13-UNDER CARRIAGE ©, :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 Ea U2 4 M M 2 OTHER 4 ❑Y ®N SYSTEM DUNK VEH. AT CRASHD 99-UNKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 COM VEH 0 Ea 1 Z ELGIN IL 60120 0 1 0 NONE IL 2024 FIRST CONTACT 12 7_: __s uYes.See siaabar u1 0 REAR TELEPHONE IL D 0 1 G 11 C5SA7DF341292 NONE ®Y 0 N U2 1- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 GM Financial NONE 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Ru,ly 0 i v 0 Dv 1 9 9 9 Honda Accord 2006 Do-NONE ,._"j 12..-_, DUETO CRASH ❑ !1 2 .. Yr 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.70P 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI S l,,_4 COM VEH ❑ ® U1 CO FIRST CONTACT 6 Y :j_O ._5 •It Yes,See Sidebar z ELGIN IL 60123 0 1 0 EW81916 IL 2025 aR 0 C IL D 0 1HGCM72726A010019 STATE FARM ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 PENA MAYORGA.JAVIER 1396856SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,31 (2024 03 50 0 pm in a Work Zone? ®N DIRP co 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 2 ❑ 28 03 ( ( ❑PM ❑Construction * 0 3 R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Tenelema Allaico. Fredy.V. 5-503 1538000076 ( r El PM SLMT o N ❑CITATIONS ISSUED I]PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility ❑AM r 2 ❑ ARREST NAME Tenelema Allaico. Fredy.V. 3-401-A 1538000079 ( 1 ❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑y 30 1538-Estrada. Leticia 400 02 (04(2025 01 30 ElPM ®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 -< ` ` --I -' r INDICATE NORTH combination):or —I N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or Not To Scale X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or c0 C __ __ '�^" 4. Is used or designated to transport between 9 and 15 passengers,including (I) } } } g po passen rs,includi the driver, t . for direct compensation(example:large van used for specific purpose):or O L i t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m — — placarding(example:placards will be displayed on the vehicle). XI m 7< CARRIER NAME I [I' Z ADDRESS 0 D c) I — CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z ' . 0 Yes 0 No ❑ Unknown A 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE