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HomeMy WebLinkAbout2024-00057818 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 11111111111 IIIIIIIIIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY XQ03560561 u, 1 U21 3 4 1 U, 1 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.5000 NOT ON S®ON SCENE • 3 VEHICLE/PROPERTY 0 OVER$1,500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2O24-00057818 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '17 N RANDALL RD ® ❑ Elgin RELATED ®Y ❑N 09 10 2024 05:18 ❑AM ® ❑YES NO u1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m Fri MI N E S W ROYAL ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n NAME(LAST,FIRST,M) y mo day yr Muna er,Abdul, B. Toyota Camry 2018 00-NONE „ Q i , DUE TO CRASH ❑ 13-UNDERCARRIAGE 19 (21 1• I 2 FIRE ❑ ® 4 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED RI 0 U2 m 972 ATLANTIC AVE C M THER ❑Y ESYlM IN❑UNK VEH. n AT CRASH ENGAGED O 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 7 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 I� 6 1 4 COM VEH ❑ ® 1 O ~ 4T1 B11 HK5JU141508 STATEFARM ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same 0652373 SFP 13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) Fi20 IT TOWED Y N NAME(LAST,FIRST,M) Taborda-Munoz.Anderson, D. mo day yr 0 9 0 9 1 9 8 2 Land Rover Range Rover 2023 00-NONE +c) 12 s OUEETO CRASH ❑❑ ® U2 14 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 0 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 O X a 2540 CARLISLE LN M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j i! 4 COM VEH ❑ ® U1 to I— FIRST CONTACT 6 7--_on-5 •If Yes,See Sidebar HAMPSHIRE IL 60140 0 DSPR-SS IL 2025 I 0 CC/j, D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (706)885-3755 T163-0048-2257 IL D SALKUBE77PA026381 STATEFARM ❑Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = DMG Consulting&Dev 0652373-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°®NR 1425 MADELINE LN . ELGIN , IL,60124 (312)533-4993 U1 i (UNIT( (SEAT) ;DOB) (SEX) {SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I{ADDRESS)I{TELEPHONE I (EMS) (HOSPITAL) n I I U2 996 r m /• - #OCCS y /• / U1 1 m I I 1 0 EV MOST EVNT LOC_DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 11 9/ /0/ /024 05 18 ®pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 0 T 2 ❑ 03 41 ! / 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ARREST NAME Tamaronis-Munayer,Abdul, B. 11-601-Ax S1533-000137 / / ❑PM SLMT CO 11 1 ❑Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N ❑ ❑ SECTION CITATION NO. AM 45 2 0 ARREST NAME 9/ 10/ /024 05 25 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? El 45 1533-Ruiz Jose 901 246-Kite 9/ I 0/ /024 09 00 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 0IF 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 r r INDICATE NORTH combination) or —I ."0 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 X ; 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 M 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 T. . ` 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 . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 Form Number 0 M X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Silver WhiteEn - 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