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HomeMy WebLinkAbout2024-00059241 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III Ifi IIII lull 11111111IllIllHl 101 1111 0111110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555519- u, 9 uz 1 1 1 1 ut 99 U2 1 U199 U2 u1 99 U2 1 4 9 Ut 1 U221 *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 SCENE0 NOT ON • 7 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash yR 20241 2 024-0 0 0 5 9241 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71 S GROVE AVE ❑Elgin RELATED ❑Y co" 09 16 2024 02:09 ®AM ❑YES ®NO U1 -( PRIVATE mo l day I yr El PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®'' ❑ " PEDALCYCUST®N 0 FREE FLOW # LNS ' 0 D4 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 .0. Unknown Unknown DO-NONE 11 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10) 2 FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER DISTRACTED 0 ® U2 m 9 16-TOP 3 r M ❑Y ❑N ❑UNK VEH. AT CRASH POINT OF UNKNOWN 8 it ii 4 COM VI EH ion�� 0 ® ALGN CITY PLATE NO. STATE YEAR } 6 1 F NIA ❑Y ❑N U2 r m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Ya Same NIA 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 99 0 m ❑DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 Y N m m / / FOR DAMAGED AREA(S) FRONT TOWED —I NAME(LAST,FIRST,M) mo day yr Porsche Cayenne 2023 DO-NONE 1t 12 ,_1 DUE TO CRASH ❑ ® 2 c 13-UNDER CARRIAGE 10 I : Y FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPCA 0 a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value g Ut 9 N POINT OF 8 j /1�i 4 COM VEH CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR all 0 ® C FIRST CONTACT 7 4_-___,_5 •ItYes,See Sidebar NJG729 OK 2025 RFAR 0 fn, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 WP1AA2AY6PDA10017 Mercury ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Zhang,Zeming OKAP000009601 8 BAC ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 5824 HAVENSHIRE LN . Edmond-OK, 73034 (331)275-8779 U1 = (UNIT) (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL) n I I U2 996 r m / / - '#OGCS D / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 18 9 09/16 /2024 02 09 ❑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: U1 2 0 T 2 0 18 99 ! / 0 PM ElConstruction * N 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 3 Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 20 T 2 0 ARREST NAME 1 / ppt ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 1532-Hernandez. Daniel 101 280-Marabillas I I El PM Workers0 Am present? ®N 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. _ 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 L I ', ' -t ` 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 carrier 0 t.----.....---% 4 i } - i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w �____A____: : 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 Not To Scare L____--____4 ; ; - i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires rn • web ' placarding(example placards will be displayed on the vehicle) 71 ' i CARRIER NAME Z ' I ADDRESS 0 N '• CITY/STATE/ZIP 2 - MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other ' USDOT NO. ILCC NO. XI , 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 M 7) 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 CJ 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 WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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