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HomeMy WebLinkAbout2024-00060193 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III HI IIIIIII II 111111111111111111101101111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANV X003560966' u, 1 U2 1 3 4 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S Ed$501-$1.500 ®ON SCENE • 3 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00060193 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'FI N STATE ST ®gin ❑ RELATED ®Y ❑N 09 19 2024 06:40 ❑AM ❑YES ®No u1 -< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W BIG TIMBER ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑ECUES 0 RIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n 0 5 / 0 6 /1 9 9 9 FOR DAMAGED AREA(S) FR Nf TOWED U1 NAME(LAST,FIRST,M) Martinez,Jary. L. mo day yr Honda Civic 2014 00-NONE 11 O� 1 DUETOCRASH ❑ 13-UNDER CARRIAGE 10 DI I I 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 04 m 546 EICHLER DR 3N F ❑Y El NSYSTEM❑LINK VEH. 0 ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 I� 6 1 4 COM VEH 0 ® 1 0 19XFB2F86EE019020 American Heartland ®Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same AHQ6006069 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 73 L ❑Y ❑N 2 G) ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 RUM ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) Fi20 IT TOWED Y N NAME(LAST,FIRST,M) Lane, Mariah. N. 1 2 Oa 1 yr 9 9 9 Honda Fit 2007 oo-NONE 1c i 12 I. _s REo CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN 0 0 a 202 SETON PL F ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y El ❑LINKVEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 4 COM VEH ❑ ® U1 to C FIRST CONTACT 6 7_•-_1-;=5 •If Yes,See Sidebar Z STREAMWOOD IL 60107 C EB11814 IL 2024 1 0 I;p D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)220-4226 L500-5549-9943 IL D JHMGD38417S009427 unknown ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same unknown BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RESPONDERY0 Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 r m - #OCCS y / /• U1 1 73 D. I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME DAM Did crash occur ❑Y U2 Z U 1 ® 11 1 91 /91 /024 06 40 0 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,ZIP ❑AM Ut 5 .. 2 0 28 03 91 /91 /024 06 49 ®PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. I EMS ARRIVED TIME 5 0 AM ❑Maintenance U2 •CO 11 1 ARREST NAME Euceda-Martinez,Jary, L. 11-601 432000914 91 l 91 /024 06 51 ®PM SLMT o U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N AM 45 2 0 ARREST NAME Euceda-Martinez,Jary_ L. 6-101* 432000915 91 /91 /024 06 41 ®PM ❑Unknown work zone type U1 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME fC ®AM Workers present? ❑Y 45 432-Obenauf. Matthew 501 334-Fries 10 /22/2024 09 00 0 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. 0F 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 properry and. D /f + , j 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i i (I) / t I f combination) or —I INDICATE NORTH XI / t! / BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , L i_ J. J. 1 L r++n� I P.o-• ! r r r (example.shuttle or charter bus)-or / / U designed to carryfewer passengers operateda carrier i_-----;---... + + i ® / -i i- } i• transporting employees the course of their employment( ample�emaployeerie OM i / transporter-usually a van type vehicle or passenger car).or 03 i.____A____: : , : r 1 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N l �` for direct compensation(example:large van used for specific purpose).or L_____L____; i ; . / i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m / placarding(example placards will be isplayed on the vehicle) XI T. // !/� / CARRIER NAME z ' / // I .. ADDRESS '� CA 7Tiii // O / CITY/STATE/ZIP r , / l. MOTOR CARR ID ❑ Interstate ❑ Intrastate / : 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. , Source of above Z _ GVVVR/GCWR ❑ <10,000 0 10,000-26,000 1=1 >26,000 z —I Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown 0 C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C Z Form Number D m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z ip Gray Blue - 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- 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE