HomeMy WebLinkAbout2024-00057887 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II
III II IIIIII UHI
II IUOUH ID
II IIIII IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463a489.,2
ut 1 U21 1 1 1 U1 9 U2 1 U1 1 U2 1 U1 1 U2 1 4 15 U,23 U2 1 �K P 0119
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 1
VEHICLE/PROPERTY ®OVER 31,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
ID AMENDED
YR 2024I 2024-00057887 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
670 WALN UT AVE El In 07
® ❑ RELATED ❑Y ®N 09 10 2024 ❑AM ❑YES N NO U1 -<
:26
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FROM T TOWED U1
HERNANDEZ. LAYSHA Toyota Camry 2023 00-NONE „ 12 , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE fal !!. 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 8 ❑Y ONSYSTEM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D its 1 Y COM VEH 0 IE 1 C)
~ ELGIN I L 60120 B 1 0 FIRST CONTACT 6 O7 _:�Q_OS •II Yes.see Sidebar U1 0
Z EK27731 IL 2024 REAR
TELEPHONE
IL D 0 4T1G11AKXPU080486 Bristol West Insurance ❑Y IlN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same G01487750200 1 1-
15 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 XI
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑!My 0 Ncv ❑DV
!1 9 8 4 Mazda CX7 2012 00-NONE O, . Qj.O DUE TO CRASH rg ❑ 2 x
O 13-UNDER CARRIAGE FIRE 0 ® U2 C
F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-,il_�:-=4 C.OM VEH ❑ N U1 CO
FIRST CONTACT 12 , _, .5 •If Yes,See Sidebar
m ELGIN IL 60120 0 1 0 L117325 IL 2025 I 0
Z So
IL D 0 JM3ER2B57C0412346 Statefarm ❑Y N N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1404973-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL)
1 1 0 5 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 N 11 1 09/10 /2024 07 26 ®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
v 2 0 30 99 09,10 /2024 07 27 ®PM El Construction
R O 0 ]$I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
-a, ARREST NAME HERNANDEZ. LAYSHA 11-1402-A W1500000272 09r 10/2024 07 31 ®PM SLMT
1 ® ElUtilit 11 1 ❑CITATIONS ISSUED PENDING
o u SECTION CITATION NO. ROAD CLEARANCE TIME y
t 2 El ARREST NAME 09/10 /2024 08 12 ®PM El Unknown work zone type U1 0 AM 30
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - El Am Workers present? ❑Y 30
1500-Chew. Marie 701 / ❑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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
0 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- -A-.--i ` }} } transporting employee �In the course of their employment(example:employee
1 1 I transporter-usually a van type vehicle or passenger car):or CO
L `.___A i Not To Scale _ �4. Is used or designated to transport between 9 and 15 passengers,including c
I. } } • •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Unn 1 Pe ( P 9 Pe or 0
L I. it t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i ; placarding(example:placards will be displayed on the vehicle). ;p
D
-- —I
CARRIER NAME Z
ADDRESS 0
w..mw. �
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown —I
D
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 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 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