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HomeMy WebLinkAbout2024-00059640 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111IllIllHl 101 11111 HI III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355553/ u, 1 U2 1 1 1 1 U, 2 U2 1 U, 1 u2 1 U1 1 U2 1 1 10 U1 3 U2 3 *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 ®$501-$1.500 ®ON SCENE 1 El NOT ON S VEHICLE/PROPERTY ElOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059640 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 E CHICAGO ST ®gin ❑ RELATED ❑Y coN 09 17 2024 04:45 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m 050 ®/MI N 0 S w WILLARD St 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 15 N Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) PEDALCYCUST El ® FREE FLOW # LNS 0 DA DRNER 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 3 C) FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 ,Gricel.S. 0 8 / 1 7 J 1 9 7 4 Ford Escape 2018 00-NONE ®i 12I , DUE TO CRASH p ® — E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE IA 10 I 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 3 m 128 N PORTER ST 3 F ❑Y IN NSYSTEM DUNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 6• !1 6 II_4 COM VEH 0 ® 1 0 ra ~ 1 FMCUOG DXJ U B99302 Direct Auto ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 9 Same PAIL001163180 1 r Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G) ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FROM TOWED Y N s Chanthavong. Dan 0 5 2 2 1 9 8 6 Toyota RAV4 2021 00-NONE O' D1 DUE TO CRASH ❑ ® 2 Xi , NAME(LAST,FIRST,M) mo day yr 'Z ✓ t3-UNDER CARRIAGE 10 Ij 2 FIRE ❑ IN U2 C : STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) E 905 KEN N ETH CIR M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y El N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF P RI8T CNT ONTACT 12 7_'1 a 1_5 C•IOMe6VSee Sidebar ® U1 to H ELGIN IL 60120 0 DB38068 IL 2024 REAR f 0 Cn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)387-9131 C531-1608-6146 IL D 0 2T3F1 RFV5MC237813 Progressive ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Chanthavong. Pasong 965820268 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 357 JOHN DR. ELGIN . IL,60120 (224)268-2363 U1 = (UNITE (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 1— m / _ '#OCCS > / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z u ® 11 1 09/17 /2024 04 45 ®pM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 1 a 2 ❑ 2 28 ! / PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 •Q CO 11 1 ARREST NAME Soto-Perez.Gricel.S. 11-902 W1507000319 / / ❑PM SLMT o UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Ulllity o N 0 ❑ SECTION CITATION NO. AM30 2 ElARREST NAME 09/17 /2024 05 37 ®PM ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1507-Ruiz.Alondra 302 - / / 0 PM AM Workers present? ®N U2 30 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 4 } 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 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------.-----• + + • : - 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 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C 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 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 g 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 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 Gray Gray - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE