Loading...
HomeMy WebLinkAbout2024-00059525 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III )III IIIIIII II 111111llIllIllHllfll IlIHIlIHhlO I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555540* u, 1 U2 1 3 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 11 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY Ill OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059525 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 'F'I ROUTE 20 EXIT RAMP HWY ❑Elgin RELATED ®Y ❑" 09 17 2024 10:13 ®AM ❑YES ®No u1 -< PRIVATE mo /day/yr El PM FLOW CONDITION m ( 50 ®/MI N E s® South ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ PEO 0 PEDAL ❑EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 1 1 / 0 9 /1 9 9 4 FOR DAMAGEDAREA(S) FRONT TOWED U1 mo day yr — 13-UNDERCARRIAGE 10l .r 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 3 m 6346 S KOSTNER AVE M SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASH 99-UUNKNOWN THER9 16-TOP 3 ,OistractlonValue 9 ALGN I r CITY PLATE NO. STATE YEAR POINT OF 8 116 I. COM VEH IZI 0 5 n jL FIRST CONTACT 12 7 t�_5 "If yes,See Sidebar U1 0 Z 3HSDWTZROLN845128 Cherokee Insurance Co ❑Y ®N U2 49 . m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Central Transport GL240010 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER y°DEN 12225 STEPHENS RD.Warren. MI .48089 (586)939-7000 VEHU > ' ®COWER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 20 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) Blissett. Kainin.G. Imo day 1 yr 9 9 9 Tesla Model 3 2024 DD-NONE '0 12 s REOCRASH ❑❑ MI U2 2 C v 13-UNDER CARRIAGE I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 0 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 0 X El E 230 HALF MOON CI R M Y N UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 j ! 4 COM VEH ❑ ® U1 to FIRST CONTACT 6 7__•- ;_5 •If Yes,See Sidebar Z Aurora IL 60504 0 91557EL IL 2025 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)849-1890 B423-5079-9313 IL D 5YJ3E1 EA3RF729534 Tesla ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same TLAILA99927REE Bnc ' E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y 0NR Same Ut _ (UNIT( (SEAT) ;DOB) (SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) {EMS) (HOSPITAL) I I U2 996 1- m / - #OCCS D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ElY U2 Z N 1 ® 11 1 co 91 /71 /024 10 13 ❑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 ID AM It YES check one below: U1 3 C) T 2 El 03 28 ! I 0 PM El Construction * c' 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 Ei AM ❑Maintenance U2 Q ARREST NAME Cepeda Palacios.Jesus. R. 11-601-Ax 410000665 / / El PM SLMT CO 11 1 0 Utility U ❑ ' CITATIONS ISSUED 0PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 45 1 D T 2 0 ARREST NAME / / pp1 El Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 410-DeLeon.Jessica 801 272-Bajak 10 / 15/2024 01 30 ®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. _ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A • ADDITIONAL UNITS FORMS r_.._r_ __. ; ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 0D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i INDICATE NORTH combination) or —I 7:1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C • I d i t • i I I -` ` r r r (example.shuttle or charter bus)-or 0 1 j 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 i------;-----� i `"`�' -f } - i• transporting employee in the course of their employment(example.employee 7, — aiti — — — — transporter-usually a van type vehicle or passenger car).or w i-____A____: : i ....+.. : l• 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 L____L____; . . , \1 I I I I i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires \` - - - placarding(example placards will be displayed on the vehicle) Zml r CARRIER NAME Central Transport Z ' .. ADDRESS 12225 STEPHENS RD CITY/STATE/ZIP Warren 1 MI /48089 To r , MOTOR CARR ID ❑ Interstate ® Intrastate Not in Comm./Govt. 0 Not in Comm./Other • r USDOT NO. 661173 ILCC NO. 302382 , Source of above Z _ xi 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 E Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID Yes No ❑ Unknown 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 2 Z Form Number 0 m XI IDOT PERMIT NO 661 173 WIDELOAD2 ❑Yes ®No = TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 53 ft 2 ft Z White Gray - u 1 TOWED TOTAL VEHICLE LENGTH 70 ft. NO.OF AXLES 5 DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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 4 CARGO BODY TYPE LOAD TYPE