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HomeMy WebLinkAbout2024-00059366 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi IIIIIII II II 11111111IllIllHl 101 1101010 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555527 u, 1 U2 1 1 1 1 U1 9 U2 1 U, 1 U2 1 u1 1 u2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1,500 ®ON SCENE • 7 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1,500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059366 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I SUMMIT ST ®gin ID ❑Y coN 09 16 2024 04:19 DAM El ®NO U1 • ,< PRIVATE mo l day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ❑SLOW 2 f/) ❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS ' 0 ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 .JOSE, D. D 8 / 1 2 /1 9 8 8 Honda Accord 2023 00-NONE 11 12 , DUE TO CRASH p DI NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE to 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 0 m 402 N PORTER ST M ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN I r CITY PLATE NO. STATE YEAR POINT OF 8 1 6 4 COM VEH 0 IZI 1 C) ~ 1 HGCY1 F38PA018541 AMERICAN FREEDOM INS ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Same 12 249046 OD 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 5 ❑Y ®N 2 G) r. ❑DRIVER ® PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 Nov ❑NOV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) Mae TOWED n NAME(LAST,FIRST,M) mo day yr Ford F150 2006 00-NONE 11 r 12 I. _1 DUE TO CRASH 0 ® 2 73 c 13-UNDER CARRIAGE 10 i I 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑ El SPDR n ❑Y (2/ N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_ 6 ji 4 COM VEH ❑ IN Ut it to 1— FIRST CONTACT 5 ® •ItYes,See Sidebar 3416598B IL 2025 I 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTRX1 2W1 6FA62037 KEMPER ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I I BAR RA ZAPATA_ RAUL 12A0000348460 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1622 MARK AVE 2. ELGIN . IL.60123 (847)276-0185 Ut = (UNIT! (SEAT) /DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE I EMS! (HOSPITAL) C) I I U2 996 r m / / - - #OcCS ' D / /• U1 1 m / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N 1 ® 18 5 09/16 /2024 04 19 0 pm in a Work Zone? El DIRP co 1 5 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: u1 C) T 2 0 30 28 ! / 0 PM ❑Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 AM ❑Maintenance uz Q ® 11 5 ARREST NAME / / _ ❑PM SLMT o U CITATIONS ISSUEDPENDING ROAD CLEARANCE TIME ❑Utility o N ❑ 0 SECTION CITATION NO. AM 15 T 2 0 ARREST NAME 09/16 /2024 8 PM El Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1519-Bae2 a.Guadalupe 201 - / / ❑Q PM Workers present? ®N U2 15 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------t-----• + + • : - -, 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 m placarding(example placards will be displayed on the vehicle) .Z1 X. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r - DO ILCC NO. m U N XI , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 Blue Blackcn - 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