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HomeMy WebLinkAbout2024-00058007 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III I IIIIIII II 11111111111111H11 1011 IIH Ill Ill I ll II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553971 u, 1 U2 1 3 4 1 U199 u2 1 U, 1 U2 1 U1 1 U2 1 1 12 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 2 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00058007 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I N STATE ST Elgin ❑ RELATED ®Y ❑N 09 11 2024 08:14 ®AM ❑YES ®NO U1 ,< PRIVATE mo l day/yr ❑PM FLOW CONDITION m FT/MI N E S W WING ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR 0 SLOW 15 N ❑ 'WITH VEHICLES INVLD ® STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 8 / 2 9 /1 9 9 6 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 .Javier, E. Hyundai Elantra 2017 00-NONE 11 1 DUETOCRASH ❑ NAME(LAST,FIRST,M) mo day yr 12 l; 13-UNDERCARRIAGE 2 FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) fzi ® O DISTRACTED 0 1l U2 m 869 Carriage WayM SYSTEM IN ENGAGED 15-OTHER O16-TOP®3 = g ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN T. CITY PLATE NO. STATE YEAR POINT OF 8 116 II COM VEH 0 El 1 0 F FIRST CONTACT 1 O 7 tl_�5 'If Yes,See Sidebar U1 0 Z KMHD84LF1 HU284515 American Alliance Insuran ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same I LAA100064000 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑N 2 GI5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 1 / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) lmo 1d a 1 9 9 7 Kia Motors Co ltos 2023 00-NONE r y DUE TO CRASH ❑ ® 2 Sridhar.Ashvin lc i 12 I:-Z FIRE ❑ ® U2 C -2 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-Tpp�j 0 E. 1431 TODD FARM DR 6 M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T IOONTACT 3 TF _II 6 l_5 C•IOMe6 VEH SeeSideba❑ ® U1 07 F ELGIN IL 60123 0 DU62649 IL 2024 REAR f 0 PI D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (312)834-8630 S636-0009-7329 IL D KNDEUCA2XP7423178 Statefarm ❑Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 1662745sfp13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0 NR Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) / I - U2 996 1- m - #OCCS > / /• 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 1 09/1 1 /2024 08 14 ❑pM in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 5 0 T 2 0 03 99 ! / 0 PM El Construction * c' ' 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 ARREST NAME Castellanos,Javier, E. 11-710-A 225-155 / / ElPM SLMT CO11 1 ' ❑Utility p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ',3N BAM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME El Y 30 225-Wolek,Thomas 272-Bajak I / ❑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. 0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I i INDICATE NORTH combination) or —I XI Iii BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver i I r� -t ` r r r (example.shuttle or charter bus)-or C I3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -f } transporting employees in the course of their employment(example.employee M transporter usually a van type vehicle or passenger car).or 03 i____A____: r, worm •-',.;_ I _i i } r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O 11 i____ ____1 i; , — — — — e.etmest i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' f ADDRESS 0l N - Not To Scale j C - O • CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr -i Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations(MCS)violation contribute to the crash? O ❑ 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 Form Number 0 m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver Gray - 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/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE