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HomeMy WebLinkAbout2024-00058714 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011000111111 0 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003552%7* u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash El AMENDED YR 202412024-00058714 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n MOHAWK DR El In 03:38 ® ❑ RELATED ®Y 0 N 09 13 2024 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT l MI N E S W PATRICIA DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 u) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NW 0 NCV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FTtOntr�TOWED U1 0mo Salazar.Jose. L. Toyota Corolla 2014 00-NONE ©, >2 �/OUETOCRASH ® ❑ NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 8 ❑Y ®SYSNEM DUNK VINEH. O AT CRASHD 0 99-UUNKNOWN THER 9 76.70P 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7 ;1 _5 *IrYes.See Sidebar U1 Z SYFBURHE IL 2024 Ismi TELEPHONE IL D 0 SYFBURHEXEP126252 State Farm ❑Y I IN U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 9459852c15-13d 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Provena St.Joseph ❑Y ® N 2 73 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 row 0 Ncv 0 Dv /1 9 8 5 Dodge Journey 2016 00-NONE 0. QI'-O DUE TO CRASH rg ❑ 2 73 ... 13-UNDER CARRIAGE 10( 12 FIRE ❑ ® U2 C c F 2 8 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16•TOP 3 9 0 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac Dn Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 co FIRST CONTACT 12 7�_,--- •If Yes,See Sidebar ~ ELGIN IL 60120 0 1 0 Q787091 IL 2024 RFJ 0 M IL D 0 3C4PDCAB7GT199159 Progressive ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 911414608 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Sherman RESPONDER u1 = (UNIT) /SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI ,(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 4 06 / :A / / UI 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 09,13 /2024 03 38 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 ❑ 23 28 / / ❑PM ❑Construction Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 o 1 ® 11 1 ARREST NAME Salazar.Jose. L. 11-1204-B 485000304 / / El Pm SLMT llg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 ❑Utility o N AM 25 r 2 ❑ ARREST NAME Salazar.Jose. L. 11-601-Ax 485000305 / / pM ❑Unknown work zone type U1 T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 485-Quintana.Josue 201 ❑AM Workers present? ❑N 25 r / ElPM ElU2 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.-- .{-- --; } } } r -, 4 4 ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (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 I- <.__-a-_-_-I , I' I' I- <--_-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____J L 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 i. ADDRESS 0 CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate O ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . IDOT PERMIT NO. WIDELOADo ❑Yes 0 No = TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v 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. Z Gray Gray 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE