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HomeMy WebLinkAbout2024-00059661 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III 010 Ifi 1In ll 11111111IllIllHl 101 1111 01111 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY •X0O3555516 u, 1 U21 2 4 1 U1 3 U2 1 U, 1 U2 1 Ut 1 U2 1 1 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El q No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00059661 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m HASTINGS ST ❑ Elgin RELATED ®Y ❑N 09 17 2024 06:27 ❑AM ® ❑YES NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W ST ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n 0 8 / 2 3 /1 9 8 6 FOR DAMAGED AREA(S) HtCNT TOWED U1 - mo day yr z 13-UNDER CARRIAGE FIRE ❑ 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 ® U2 0 m 280 NORMAN NELSON CT F SYTHER ❑Y ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UNKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 1 6 i+• 4 COM VEH 0 ® 1 O FIRST CONTACT 12 7_ :{_�5 ^Yves,See Sidebar 1.11 0 Z KM8NU13C59U097476 No insurance ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same No insurance 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU 73 L ❑Y ®N 2 0®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUM ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N s Ventura,AI ssia.C. 0 7 1 8 1 9 7 8 Toyota Highlander 2018 00-NONE © 1 0 0 2 xi NAME(LAST,FIRST,M) y mo day yr Q, v 13-UNDER CARRIAGE 9 I i 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 ® SPOR 1) a 1126 IRONWOOD DR F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y MI N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value to N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CNT OONTACT 12 7_'1 a 1_5 FCIOMe6VSee Sideba❑ ® U1 ~ C ELGIN IL 60120 0 AU40553 IL 2025 I 0 Sn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)234-7223 V536-0037-8804 IL D 0 STDBZRFH1JS869382 Statefarm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 6482730C1813E BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI IEJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME!,(ADDRESS)H(TELEPHONEI (EMSi (HOSPITAL) 1 3 12 /1 5/1990 M 2 3 0 1 0 Angelo D. Johnson/2766 CAROL PL.Rockford.IL.61109 (331)222-1871 _Elgin Fire Refused U2 996 m 2 4 05 /31 /2012 F 2 3 0 1 0 Avery Ventura/1126 IRONWOOD DR,ELGIN.IL.60120 Elgin Fire Refused #occs y {224)234 7223 g X / / U1 2 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 4 09/17 /2024 06 27 ®PM in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 2 ❑ 23 99 09,17 /2024 06 27 ®PM El Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 ® 11 4 ARREST NAME Henry. DeLeon, R. 11-1204-B 1500000273 09/17/2024 06 32 ®PM SLMT o u CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ❑Utility ® SECTION CITATION NO. � AM 35 I 2 0 ARREST NAME Henry. DeLeon. R. 3-707 1500000274 09/1 7 /2024 07 09 ®PM ❑Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1500-Chew, Marie 401 334-Fries 10 ,21 /2024 09 00 0 PM Am workers present? ®N U2 35 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 ( I 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r { N 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 ', ', i ! ` r r r (example shuttle or charter bus) or I _Not TO Scale 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 0 -- - I i- - i transporting employees in the course of their employment(example.employee ;a unit 2 transporter-usually a van type vehicle or passenger car).or CO Naatlngs?St , i i r , 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C until `� for direct compensation(example:large van used for specific purpose).or O ___1 ; 1 _ — i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 rn placarding(example placards will be displayed on the vehicle) 71 r CARRIER NAME Z ADDRESS 0 gS N ICITY/STATE/ZIP MOTOR CARR ID ❑ ❑ Intrastate ❑ NotInterstate m Camm./Gout. El Not in Comm./Other Q C USDOT NO. ILCC NO. , Source of above Z . 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? ❑ 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 2 Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m D 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 Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: Redmons I Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: DUE TO ❑ © Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE