Loading...
HomeMy WebLinkAbout2024-00060331 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III IIII IIIIIII II II 11111111111 11001101 1011111 110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003560996 u, 1 U2 1 1 1 U, 5 U2 1 U, 1 U2 UI 1 U2 1 1 9 Ut 1 U221 *PO 1 1 9* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 1 0 NOT ON VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00060331 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 'n LEAWOOD DR ❑Elgin RELATED ❑Y coN 09 20 2024 12:06 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 050 ® O 'COUNTY PROPERTY El ®N DOORING ❑'' #OF MOTOR ❑SLOW 15 N I MI N E S W Briarwood Dr 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EOUES 0 NW 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) FOR DAMAGEDAREA(S) FBG*IT TOWED U, O . Marisa 1 1 / 1 0 J1 9 6 8 Ford Escape 2014 00-NONE ®i 12 , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( FIRE ❑ 21 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® 2 DISTRACTED 0 53 U2 m 639 LINCOLN AVE F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6• !1 6 ii 4 COM VEH 0 ® 1 0 F 1 FMCU9GX8EUA90406 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 1 99 9 Alvarado. Felipe d20-3575-c23-13f 1 r o IF HOSPITAL(TAKEN TO) INCIDENT 'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER o RESPONDER 3 639 LINCOLN AVE. Elgin. IL.60120 (630)313-0632 VEHU GI m 0GI DRIVER ® PARKED 0 DRNERLESS 0 PED ❑PEDAL 0 EOUES 0 NlAV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr General Motor9�ip 2013 oo-NONE 1t. 12 ,_1 DUE TO CRASH ❑ ® 173 c 13-UNDER CARRIAGE ®) .? 2 FIRE El ICI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 IN SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN ••Distraction Value 9 U1 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ©I 11 4 COM VEH ❑ cgi FIRST CONTACT 10 Q. 6 -5 •If Yes,See Sidebar CK92768 IL 2024 I 0 CCn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 G KKVTKD6DJ 177748 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Perez.Angel 969285485 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < DY RESPONDER 1310 LEAWOOD DR. ELGIN . IL.60120 (773)691-1272 U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) )INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL) n I I U2 996 r m / / - #OCCS y / / U1 1 m / I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z N 1 ® 18 1 09/20 /2024 12 06 0 pti, in a Work Zone? El DIRP CO 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 C) T 2 ❑ 20 18 ! / 0 PM El Construction * t N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM El Maintenance U2 3 Q • ARREST NAME Alvarado. Marisa 11-709-A 324-1412(W) / / El PM o ® 11 1 U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT ',3N B AM 30 2 ❑ ARREST NAME 1 / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 324-Phillos.James 202 275-Engelke , / 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. , r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . 0 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z r-"--r--- 4 , 4 r r r r r , , , , . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r i ; i ; i- r r , , i r r INDICATE NORTH combination) or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! t- ' ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------'-----• + + • : - -, 1 1 1 i } - i• transporting employees in the course of their employment(example.employee M 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 ' t ADDRESS 0 N • • CITY/STATE/ZIP , , . MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not m Comm./Govt. El Not in Comm./Other Q C r-----.-----, r r r r r•---, i - DO ILCC NO. m U N XI , Source of above Z . GVVVR/GCWR ❑ <10,000 0 10,000-26,000 0 >26,000 Z Were HAZMAT placards on vehicle'? ❑ Yes ❑ No 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 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 Form Number 0 M X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Red WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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