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HomeMy WebLinkAbout2024-00057057 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III )III III ll II 111111111111111111101 11111110110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003560940* u, 1 U21 2 4 1 Ut 7 U2 1 Ut 1 U2 1 Ut 1 U2 1 4 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00057057 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '17 VILLA ST Elgin ❑ RELATED ®Y ❑N 09 07 2024 08:35 ❑AM El YES ®NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W BENT ST 'COUNTY PROPERTY El Y ®N DOORING ❑y #OF MOTOR ID SLOW 15 N ❑ Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH /NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIa ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FRONT TOWED Ut 0 Buick Lucerne 2007 00-NONE DUE TO CRASH / J NAME(LAST,FIRST,M) . B. mo day yr 11- Q O ❑ 13-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) to z DISTRACTED 0 ® U2 2 m 34W988 CLYDE PKWY M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH 0 ® 1 0 FIRST CONTACT 12 7_ ? 6 :_.5 ^Yves,See Sidebar U1 Z 1G4HP572X7U236107 Kemper ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same 12A0001481190 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 G) 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED n NAME(LAST,FIRST,M) Rivera.Abrianny.A. 0 6 0 7 mo 2 D 0 8 Mitsubishi Outlander 2019 oo-NONE 11_0 12 s DUE TO ❑❑ ® U2 2 C v yr 13-UNDER CARRIAGE I I FIRE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X E. 2 MIDDLESEX RD 15 F ❑Y ® N El UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE No STATE YEAR POINT OF 8 j 4 COM VEH ❑ ® U107 I— FIRST CONTACT 7 4_1-;=5 •UYes,See Sidebar Z Carpentersville IL 60110 0 DH33461 IL 2025 REAR O Sn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)762-2404 R160-0010-8762 IL D 0 JA4AZ3A33KZ006887 Statefarm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Lugo Dominguez.Sue. H. K109483C2813A BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 2 MIDDLESEX DR 15.60110 (224)410-6545 U1 = (UNIT' i SEAT) (DOB) (SEX) i)SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)/iTELEPHONEI (EMS) (HOSPITAL) 2 6 05 /01 /2009 F 2 3 0 1 0 Zurely Rivera/2 MIDDLESEX DR 15.60110 U2 996 m 2 4 05 /25/2013 M 2 3 0 1 0 Yaedziel Lugo/2 MIDDLESEX DR 15.60110 #OCCS > 2 3 07 /02/1990 F 2 3 0 1 0 Sue H. Lugo Dominguez/2 MIDDLESEX DR 15,60110 Ut 1 m (224)410-6545 D / I 4 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 11 1 91 /12 /24 02 35 ❑pM in a Work Zone? El DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 3 C) T 2 0 28 03 ❑AM r ! / 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 •Q ® 11 1 ARREST NAME Just,Vincent, B. 11-601-Ax 51526000212 / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Utility o N ❑ ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 91 '12 /24 09 45 RI RA0 Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1526-Walsh.Jacob 401 - 91 , 41 /024 01 30 0 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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' } 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 truckrtrailer -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? JD Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Tan White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE