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HomeMy WebLinkAbout2024-00058352 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III )III IIIIIII II 11111111111111H11 1011 11111111101 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553945 u, 1 uz 1 1 9 1 U1 9 u216 U1 1 U2 1 U199 U2 99 1 10 U123 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE • 7 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00058352 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'I N SHADY OAKS DR ❑Elgin RELATED ❑y co" 09 11 2024 03:30 ❑AM ❑YES ®NO U1 • .‹ PRIVATE mo l day/yr ®PM FLOW CONDITION m 'COUNTY PROPERTY El Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 N ❑ FT/MI N E S W Cook HIT&RUN ❑Y ® " WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS ' 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NNV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 6 / 2 2 J 1 9 6 3 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 ,S. Mitsubishi Outlander 2019 00-NONE it 12 i' 1 DUE TO CRASH ❑ 21 3 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® U2 m 756 BENT RIDGE LN M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF 1I6 COM VEH 0 El 1 0 FIRST CONTACT 5 7_ 0 "IfYes,See Sidebar U1 0 Z JA4AZ3A30KZ030967 Statefarm ❑Y ®N U2 m V.ci, EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same 2083662sfp13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X 2 ❑Y ❑" 05 ®DRIVER ❑ PARKED ❑CRNERLESS ❑ PED ❑PEDAL ❑EQUES ❑ROV ❑NCV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED s Rios Macedo- Ignacio 0 7 3 1 1 9 5 3 Mitsubishi Outlander 2015 00-NONE O' t DUE TO CRASH 0 DA 2 —I NAME(LAST,FIRST,M) g mo day yr 10:, 12 I Y FIRE ❑ ® U2 C c 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 E 104 JOSLYN DR M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO P RI8T CO _CONTACT OF 7 '1 8 116 •CIOMeeVSee Sidebar IN U1 H C ELGIN IL 60120 0 DB38577 IL 2025 9 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED Z U2 0 (224)508-9422 R252-4005-3217 IL D JA4AD3A32FZ013107 Statefarm ❑Y El RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 99 I Same 0400354sfp13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑ Same Ut _ (UNIT) i SEAT) IDOBi (SEX) (SAFT) (AIR) IINJI (EJCT) (EPTHI PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS))ITELEPHONE) (EMS( (HOSPITAL) 2 3 09 /27/1957 F 2 4 0 1 0 salustia segura/104 JOSLYN DR,ELGIN,IL,60120 U2 996 1847)275-7475 m / / #OCCS D / / lit1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 1 1 5 09/12 /2024 11 01 ❑pM in a Work Zone? ®N DIRP D IN PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: 0 T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 3 ai 2 0 2 99 ! / 0 PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q CO 11 5 ARREST NAME / / ❑PM ❑Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N 8 AM 99 T 2 0 ARREST NAME r / pti1 ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM workers present? ❑Y 99 560-Martirez.Samantha 201 272-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. 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------.-----• + + • : - -, 1 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 . own tank)? ❑ Yes ❑ No ❑ Unknowr 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 En Gray Red - 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