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HomeMy WebLinkAbout2024-00058689 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100011111 III I11100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003552976 u, 1 U21 2 3 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 7 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and/or Tow Due To Crash YR 202412024-00058689 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n SOUTH ST Elgin 01:57 ® ❑ RELATED ®Y 0 N 09 13 2024 ❑AM ❑YES ®NO U1 -< g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1 FT N E S W S EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Reyes.Jonathan. M. 0 9 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El U2 2 (T1 M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 �i 4 COM VEH 0 Ea 1 0 ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_;1 -__5 *II Yes.See Sidebar U1 Z R527484 IL 2025 REAR TELEPHONE IL D 0 1 N4BL3APXDC156165 American Family ❑Y Il N U2 I' 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Reyes.Celestino 1628-3424-07-05-FPPA 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV yr 12 0 13-UNDER CARRIAGE 10/ z FIRE ❑ ® U2 C co F 2 4 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 i 6 i.!., C.OM VEH ❑ ® U1 W FIRST CONTACT 1 7 _,-_5 •It Yes.See Sidebar C ELGIN IL 60123 0 1 0 EA38073 IL 2025 I Si)0 IL D 0 4T1 B11 HK9KU208967 Magnum Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Garcia.Jesus PAIL001185333 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)(TELEPHONE) (EMS) (HOSPITAL) 2 6 07 / 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 El 11 4 09,13 /2024 01 57 ®AM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n T o" 2 ❑ 2 28 / / ❑PM• ❑Construction Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Reyes.Jonathan. M. 11-901-A (w)5348-1333 / / El PM SLMT o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 30 t 2 ❑ ARREST NAME AM T / / pM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ID AM Workers present? D Y 30 348-Rapacz.Jordan 601 275-Engelke / / ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 i. <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. 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 No ❑ 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'; 0 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Red 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE