HomeMy WebLinkAbout2024-00058504 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III I IIIIIII II 11111111111111H11 1011 101111111111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553966
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00058504 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
W HIGHLAND AVE ® ❑ 10:1
Elgin RELATED ❑Y CON 09 12 2024 9 ❑AM ❑YES ®NO U1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
EP0 ® O 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW CI)
/MI N S W Vincent PI 'WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 2 / 0 5 /2 0 0 4 FOR DAMAGED AREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) . P. mo day yr Toyota Camry 2016 00-NONE „ O 0 DUE TO CRASH El
,3-UNDERCARRIAGE to z FIRE ❑ IAE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m
485 ENTERPRISE ST M SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASH 99-UUNKNOWN 9 16-TOP 3 Distraction Value 2 ALGN =
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PLATE NO. STATE YEAR POINT OF 9 i 6 4 COM VEH ❑ El 1 C)
jL FIRST CONTACT 1 7_ ? _6 ^Yves,See Sidebar U1 O
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4T1 BF1 FK6GU235717 STATE FARM ❑Y ®N U2.19 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
III 99 9 Same 3383185SFP13 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU 73
L ❑Y ®N 2 GI
0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑CONES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m / / FOR DAMAGED AREA(S) FRONT TOWED
fi1 DUE TO CRASH 0 0
NAME(LAST,FIRST,M) mo day yr 00-NONE 11 12 C
c 13-UNDER CARRIAGE 10 I I 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPOR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value U13
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II a I_s C•IOMe63eeSideba❑ ❑ C
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H R C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 000 <
D YO0NR Ut I
(UNITE (SEAT) (DOB) (SEX) )SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONEI (EMS) (HOSPITAL) n
/ / U2 m
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/ / - #OCCS D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 1 3 City of Elgin ROAD SIGN 09/12 /2024 10 19 ®pm in a Work Zone? ®N DIRP CO
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 8
2 0 42 3 150 DEXTER CT ELGIN IL 60120 28 99
! I PM ❑Construction *
N 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2
Q ARREST NAME Duarte.Tyler, P. 11-502.15- 751561 / / ❑PM SLMT
o u1 I2I CITATIONS ISSUED ❑PENDING ROAD CLEARANCE TIME 0 Utility
o N SECTION CITATION NO. AM 20
2 0 ARREST NAME Duarte.Tyler. P. 11-601 751559 09/12 /2024 10 19 ®PM 0 Unknown work zone type Ut
¢ T
• OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 3 ❑ 0 AM Workers present? El1535 Solis. Laura 601 246-Kite / 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.
_ 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 1 . combination) or —I
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i ', ', i -` ` r r r (example.shuttle or charter bus)-or n
X
® 3 Is designed to carry 15 or fewer passengers and operated by a contract Carrie
r
-- -- ; 1 i m Sm., t t I. : transporting employees in the course of their employment(example employee
Met transporter-usually a van type vehicle or passenger car).or w
r i 4 Is used or designated to transport between 9 and 15 passengers including the driver, N
r for direct compensation(example.large van used for specific purpose).or O
L____-:_____; i ; , .a�.r� ` -: i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
� I ` i placarding(example placards will be isplayed on the vehicle) XI
CARRIER NAME
' t ADDRESS 0
w = N
e`
• CITY/STATE/ZIP 0
r ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0
0 Not in Comm./Govt. El Not in Comm./Other
r , USDOT NO. ILCC NO.
, Source of above Z
. —I
Were HAZMAT placards on vehicle? ❑ Yes ❑ No
If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No P3
73
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 0
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 D
m
73
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
D
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
WhiteEn
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 8 TOWED BY/TO
Redmons 1 Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOE EDTO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- TOWED BY/TO.
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE