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HomeMy WebLinkAbout2024-00059675 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III IIII lull 1111111111111111111011111111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND ' LGHT COLL MANY X0035 939 u, 9 U2 1 1 1 U199 U2 U,99 U2 U,99 U2 1 3 1 U, 1 Uz 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00059675 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71 HIAWATHA DR ® ❑ Elgin RELATED ®Y 0 N 09 17 2024 07:56 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W JEFFERSON ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0 DI DRIVER 0 PARKED ❑CRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 say ❑Ncv 0 or DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / , FOR DAMAGEDAREA(S) FRONT TOWED Ut .0. Unknown Unknown DO-NONE l� 12 i' , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE io l 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m M SYSTEM IN g ENGAGED 9 15-OTHER 9 16-TOP 3 = ❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 i' 4 COM VEH 0 El 1 0 F UNKNOWN Unknown ❑Y ❑N U2 I— m M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Ya Same Unknown 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU L El ®N 99 G') ❑DRIVER ❑ PARKED 0 DRIVERLESS x PEE ❑PEDAL ❑EOUES 0 NUM ❑Ncv 0 DV DATE OF BIRTH U1 MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m m FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Soto.Steven.G. 0 1 / O 8 J 2 0 day y0 9 r Unknown Unknown 00-NONE 12 y R TOCRASH 0 0 U2 2Xi v 13-UNDER CARRIAGE _Z C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 0 SPDR SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 a 1191 HIAWATHA DR M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •DistracoonValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO P RIST NT COONTACT F 11 7_1' 8 I_5 C•IOMesVSee 0 ❑ U1 C to H Elgin IL 60120 B TEAR Sidebar 0 In M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)629-8796 NONE K6F0002480 ❑Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 49 1 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < RESPONDER YOEl NR Ut I (UNIT) (SEAT) (DOB) (SEX) (SAFT( (AIR) (INJ( (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m / / - #OcCS y / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POUCE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 12 1 09/17 /2024 07 57 ®pm in a Work Zone? ®N DIRP co 1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AMUt 5 2 0 06 2 09/17 /2024 08 00 ®PM ❑Construction * c' 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 AM ❑Maintenance uz Q ARREST NAME 09/17/2024 08 06 ®PM SLMT 1 CO 11 1 <0 Utility p UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N 0 ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 09/17 /2024 08 39 El RA0 Unknown work zone type Ut r,f Co T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 476-Ramos.Clarissa 201 334-Fries / / p 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. 0 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. 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z r I I ; i combination).or 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 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_. ..... _. 4 i -i } - i transporting employees in the course of their employment(example.employee 7) transporter-usually a van type vehicle or passenger car).or 0 i.____A____: : i , : i 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____--____; i . ti..,........ y 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m placarding(example placards will be isplayed on the vehicle) 71 'e� CARRIER NAME —I ' ItJellomnSige .. ADDRESS D N ' • CITY/STATE/ZIP O ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate • 0 Not in Comm./Govt. ❑ Not in Comm./Other Q f < Not To Scale 1 "- '- � USDOT NO. ILCC NO.r- �-" � � m XI , Source of above Z • . ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash? ❑ Yes 0 No ❑ Unknown A 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 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 Red Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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