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HomeMy WebLinkAbout2024-00059472 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III HI III ll II 111111llIllIllHllfll llfllfllllllU I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555529- u, 1 U21 1 1 1 U1 8 U2 1 U, 1 U2 1 Ut 1 U2 1 5 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059472 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'FI DUNDEE AVE Elgin ❑ RELATED ❑Y coN 09 17 2024 05:36 ®AM ❑YES ®No u1 ,< PRIVATE mo /day/yr ❑PM FLOW CONDITION m ^,Oi1� O COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) 12Sr- ICJ/MI N E S W River Bluff ) Kane HIT 8 RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 ORNER ❑ PARKED 0 DRIVERLESS ❑ PED O PEDAL ❑EOUES 0 NIN ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) 0 3 / 0 2 /1 9 6 9 FOR DAMAGEDAREA(S) FROM TOWED U1 Ma ana,Abel Jeep(after 19ESnd Cherokee 2014 00-NONE 11 DUE TO CRASH 0 NAME(LAST,FIRST,M) g mo day yr 12 ' E 13-UNDER CARRIAGE io) 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 4 m 460 TULSA AVE M ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 *Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 ® 1 0 1C4RJFBG8EC226732 Safeway ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m or Same 39152231LPP003 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 GI 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Velez.Alex Omo 5 0 ay 2 0 0 2 Dodge Challenger 2010 00-NONE 1o) 1$ s RE o CRASH ❑❑ ® U2 2 C v yr 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 1) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X E 29 DEVONSHIRE CIR M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •DistracoonValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 8 _II a -_5 CIOMe6 Bee SidebaH r ISi U1 al H ELGIN IL 60123 0 EM69699 IL 2025 REAR •f 0 in M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)243-3563 V420-0000-2127 IL A 7 2B3CJ4DV5AH259914 Horance Mann ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 65002001880101 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑YSame U1 = (UNIT( (SEAT) (DOBi ISEX) ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) / I - U2 996 1- m - '#OCCS > / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 11 1 91 /71 /024 05 36 ❑pM in a Work Zone? Ill N DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C) T 2 ❑ 20 99 ! I 0 PM ❑Construction * N T 3 0 izl CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Martinez Magana,Abel 11-708 1530000081 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N BAM 30 2 0 ARREST NAME r / ppl ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1530-Soto,Oscar 102 - 11 , 12/2024 09 00 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. r 0 IF 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 i combination) or —I INDICATE NORTH XI 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 n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 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 . ` 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----, i '- DO ILCC NO. rn U N XI , Source of above Z • . ❑ Yes 0 No ❑ Unknown A 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 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White 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