HomeMy WebLinkAbout2024-00059521 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003557065
u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 1 .P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2024I 2024-00059521 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
® ❑ RELATED ®Y 0 N 09 17 2024 ®AM ❑YES ®NO U1 '<
UMBDENSTOCK RD Elgin09:57
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FTlMI N E S W HOPPS RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD DO
U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IN N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FRorar TOWED U1 Q
mo
De La Torre.
yr 13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) O 2 DISTRACTED 0 0U2 2 m
F 2 8 El ®SNE❑ n 15-OTHER
UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 0 t6-TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� B �'.4 COM VEH 0 El 1 n
H 1- ELGIN I L 60123 B 4 1 FIRST CONTACT 11 Qi _: --5 *If Yes.See Sidebar U1 0
Z20240722 IL 2024 REAR
TELEPHONE
IL D 0 SFNYF4H91 BB080442 Progressive ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 979891972 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 5 6 Acura TL 2004 00-NONE 0. QI'-O DUE TO CRASH 0 ❑ 2 x
0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S . ,_4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 TA—J.._, .5 •IfYes, •See Sidebar
= ELGIN IL 60123 C 1 0 CF91425 IL 2024
IL D 0 19UUA66224A039703 Freeway Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Harris.Anthony ILS 1034155-00 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)
1 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 09/17 /2024 10 00 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 .,
v 2 ❑ 06 2 09/17 /2024 09 57 ❑PM ❑Construction *
4
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
®AM ❑Maintenance U2
a ® 11 1 ARREST NAME De La Torre.Graciela 11-902 476000290 09/17/2024 10 01 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM 30
r 2 El ARREST NAME 09/17 /2024 10 48 MPM ElUnknown work zone type U,
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos.Clarissa 702 404-Duffy 10 , 15/2024 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
` ` ' ' ® r INDICATE NORTH
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
combination):or -<
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
X
L A 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
Unit 2 transporter-usually a van type vehicle or passenger car):or w
Hoppe?Rd p•�•t' I. lir
• } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or o
L L____a____� L L iany t 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
--
CARRIER NAME
Z
�y� _ ADDRESS D
29Ei. i. i. i. 4. rA
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale I 0 Not in Comm./Govt. 0 Not in Comm./Other 0
‘I. - --• - USDOT NO. ILCC NO. C
m
XI
Source of above z
. ❑ 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Silver
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 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE