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HomeMy WebLinkAbout2024-00060018 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III (III III ll II 1111111111111111111H1 III 111111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003560956' u, 1 U21 2 4 1 U1 2 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 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) 0 B Injury and JorTow Due To Crash YR 2O24I2024-00060018 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT S LIBERTY ST ❑Elgin RELATED ®Y ❑N 09 19 2024 07:57 ®AM ❑YES ®NO U1 ,•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W LAUREL ST 'COUNTY PROPERTY El Y ®N DOORING ❑y #OF MOTOR CI 1 U) ) Kane HIT&RUN El CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES ❑NW ❑soy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 C) 0 9 / 0 6 /2 0 0 6 FOR DAMAGEDAREA(S) FRONT TOWED U1 mo day yr ® >Z - 13-UNDERCARRIAGE �pl 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 M U2 02 m 1201 B R I STO L M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 'Distraction Value 9 ALGN = T. CITY PLATE NO. STATE YEAR POINT OF 8 6 4 COM VEH ❑ ® 1 0 F WVWHV7AJ5AW182930 Country Financial ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m August,Todd- M. P12A8852855 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o 0 y°®EN 1201 BRISTOL. Elgin. IL.60123 (847)345-4639 VEHU 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N s Tina ero, Rosaizela.J. 0 9 0 4 1 9 8 5 Buick Verano 2014 00-NONE a i O DUE TO CRASH ❑ 21 2 -I , NAME(LAST,FIRST,M) 1 mo day yr =., ✓ ,13-UNDER CARRIAGE 10 fj z FIRE ❑ 0 U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X E 471 S ALFRED AVE F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN II 'Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7_'1 6 �_5 CIOMeeVSee Sidebar 0 U1 C H ELGIN IL 60123 0 CE43411 IL 2025 I 0 I M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)856-7835 T526-7308-5852 IL D 1G4PP5SK8E4111736 Direct Auto ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same PAIL001181988 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER yO®N Same U1 = (UNITE i SEAT) (DOBi (SEX' (SAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAMEI f(ADDRESS)/(TELEPHONE( (EMSi (HOSPITAL) 1 3 12 /04/2006 M 2 3 0 1 0 Issac Martinez/579 DEAN DR,SOUTH ELGIN,IL.60177 996 r (630)659-9148 , U2 m / / #OCCS D / / UI 2 m / 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 /91 /024 07 57 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 a 2 El 2 28 ( I PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 •Q ® 11 1 ARREST NAME August,Adam.T. 11-901-A 1508000526 , / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ❑Utility o N SECTION CITATION NO. AM 30 2 ElARREST NAME 91 1 9/ /024 08 40 El RA0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 ❑ 1508-Salgado. Leandro 302 310-Zierk 10 , 15,2024 09 00 El RA 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. _ 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. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r 1 - 1 Laurarat INDICATE NORTH combination) or XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n I i I -t ` r r r (example'.shuttle or charter bus)-or C I4.N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.-----t-----+ + + i 'r - t transporting employees inthe course of their employment(example employee a NotScale I transporter-usuall a van type vehicle or passenger car) or w i_____A____: i t I : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N i saU te1ar : for direct compensation(example.large van used for specific purpose).or O L_____�____; . + i 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires LMIt2 placarding(example placards will be displayed on the vehicle) 11 71 CARRIER NAME I ADDRESS 0 N ' • • I CITY/STATE/ZIP I < r , , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Gov) El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above Z • . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No M 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? 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 Form Number 0 m IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 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 ft 2 ft. Z Black Gray u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: Redmons 1 Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 2 TOWED BYJTO. DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE