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HomeMy WebLinkAbout2024-00058762 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets liii Ill DIII III (III IIIIIII II 111111llIllIllHlllflll 1111111111101 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL •MANY X003553949* u, 9 U21 1 1 1 Ui 7 U2 1 U199 U2 1 U1 99 U2 1 5 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 2 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00058762 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 7l S RANDALL RD ® ❑ Elgin RELATED ❑Y coN 09 13 2024 07'36 DAM ❑YES ®No U1 .( PRIVATE mo l day/yr ®PM FLOW CONDITION m 1 O(]�/MI N E S W Route 20 ) Kane HIT&RUN ®Y ❑ N PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 ORNER 0 PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL 0 EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGED AREA(S) FRONT TOWED U1 O ,O. / / Unknown Unknown Do-NONE Q..O..0 DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10IA fzi SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 El U2 4 m ion r / ❑Y ❑N ❑UNK VEH. AT CRASH POINT99-UNKNOWNON s 4 COtr VI EH Value 0 ® ALGN CITY PLATE NO. STATE YEAR 6 4 0 F ID VIN INSURANCE CO. EXPIRED 4 NONE ❑Y ❑N U2 1.1 I— m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y r Same NONE 1 I o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 5 • ❑Y ®N 99 0®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / 27 J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Maldonado, Beatriz lmo day 1 9 9 1 Kia Motors Col�orento 2019 oo-NONE yr 13-UNDER CARRIAGE 11_ 12 2 FIRE ❑TO ❑ ® Uz 2 C v10 c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR C) a 324 CENTURY DR F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ElElO N UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8. 1 4 COM VEH 0 ® U1 to FIRST CONTACT 6 Q 0•*Yes.See Sidebar C Hampshire IL 60140 0 AABA-WS IL 2025 _ O cn TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)949-0524 M435-0609-1937 IL 0 5XYPKDA52KG468027 State Farm INS ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Solis,Alexandro K093499C1713 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < POND 0 XI N 324 CENTURY DR. Hampshire. IL.60140 (773)949-1959 Ut = (UNIT' (SEAT) (DOBi (SEX) ISAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS 8 WITNESS ONLY (NAME),{ADDRESS)I(TELEPHONEI (EMSt (HOSPITAL) 2 6 03 /20/2017 F 12 4 0 1 0 Amaya Solis►324 CENTURY DR,Hampshire.IL.60140 996 m U2 m / / #OCCS ' D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 1 1 1 09/13 /2024 07 36 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: Ut 5 C) T 2 ❑ 03 28 ! / 0 PM ❑Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 5 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AMpt ❑ 45 1 2 0 ARREST NAME 1 / pUnknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 465-Dorado.Ariana 801 - i / ❑Q PM workers present? ®N U2 45 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r r-----.-----; ; i , I I I -� A CMV is defined as any motor vehicle used to transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I ; i I I I -' ' INDICATE NORTH combination).or —I ,� I IL I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver XI I ', i -t ` r r r (example'.shuttle or charter bus)-or r a ' IIt 1 I 1 } t po trig employeeslin thecourseaottheirempbyment(example�emapbyeerie °M 3 Isf transporter-usuallyavantypevehicleorpassengercar) orwi_____A____: : J f/ IP I : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) for direct compensation(example:large van used for specific purpose).or O L____-:_____; i ; , -: i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI — — — I. CARRIER NAME Z rioumTm I I ADDRESS 0 N ' I I CITY/STATE/ZIP Not To Scale MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. ,• Source of above Z . 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 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 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z BlackEn - 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