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HomeMy WebLinkAbout2024-00058113 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III HI IIIIIII II I 6a 11111111111111H11 IIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355397 u, 1 U21 1 1 1 U1 U2 U2 1 Ut 1 U2 1 U1 1 U2 1 1 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE I El NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00058113 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 'IT CASTLE PINES CIR El ❑ Elgin RELATED ❑Y coN 09 11 2024 03:00 ❑AM ❑YES ®No ut -< PRIVATE mo l day/yr ®PM FLOW CONDITION m 1 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 3 Cl) ® �/MI N E CI W Aronomink ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / 2 4 /1 9 6 0 FOR DAMAGEDAREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) .G. mo day yr International1 Mfg 2014 ®-NONE 11 1$ , DUE TO CRASH ❑ ® - E 13-UNDER CARRIAGE 10) 2 FIRE 0IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 1 m 504 LITTLETON TRL M ❑Y ®SYSNEM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH 0 El 1 0 a ~ 4DRBUAANXEB485235 Alliant ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a U-46 P4-1001458-2425-01 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER L RESPONDER 353 N CLARK ST. Elgin. IL.60120 VEHU 0 ❑DRIVER ® PARKED ❑DRIVERLESS ❑ PEE ❑PEDALL ❑EQUES ❑NlAV ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 28 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Chevrolet Express 2019 00-NONE 1 12 ,_t DUE To CRASH ❑ ® 273 c 13-UNDERCARRIAGE 10j I. 2 FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED Q 15-OTHER 9 16-TOP 3 0 ® SPDR n ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN a 4 •Distraction Value 9 U1 0 - POINT OF cgiN CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH 0 FIRST CONTACT 11 7.'1.6 5 It Vee,See Sidebar C 2917020B IL 2024 I 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 GCWGAFP8K1162553 Brown and Brown ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 6 i Durham.Christophe.W_ A3355424 BAC ' $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDE0Y O NR 1895 CASTLE PINES CI R. ELGIN . IL.60123 Ut = (UNIT( I SEAT) ;DOB' (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'HADDRESS)1(TELEPHONE) EMS) (HOSPITAL) 1 7 / / 1 4 0 1 0 Ayden Degadillo/269 WIDSOR CT A.South Elgin.IL.60177 996 U2 m m 1 7 / / 1 3 0 1 Eleil Sosa/400 S COLLINS ST.SOUTH ELGIN-IL.60177 #OCCS D 1 7 / / 1 4 0 1 0 N'iyece Cowper/355 N LAFOX ST 402,SOUTH ELGIN,IL,60177 Ut 6 m 1 7 / / 1 4 0 1 0 Zayne Winrey/712 GENEVIEVE DR,SOUTH ELGIN-IL-60177 o EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ®Y U2 Z N ® 18 1 09/1 1 /2024 03 00 0 pM in a Work Zone? ❑N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C) T 2 0 13 99 ! / 0 PM El Construction * 1 or 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ®Maintenance U2 7 Q ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 20 T 2 0 ARREST NAME r / pti1 Ut ❑Unknown work zone type OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1534-Santjago.Jorge 702 - / / ❑Q AM Workers present? ®❑Y U2 20 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 4 } 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 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 • . 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID 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 Yellow White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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