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HomeMy WebLinkAbout2024-00060369 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 11111111111 110 II 111111111111 110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003561OO8 u, 1 U2 1 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 1 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00060369 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 't'I S STATE ST ® In El ®Y ❑N 09 20 2024 02:15 ❑AM ❑YES ®No u1 .< g PRIVATE mo l day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 U1 ❑ FT/MI N E S W 'WITH VEHICLES INVLD ElSTOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRNER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 8 / 2 8 /1 9 9 6 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) ,Sidney,J. mo day yr Chevrolet Silverado 2016 00-NONE DUE TO CRASH N-i 1$ D 0 13-UNDERCARRIAGE FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ISI U2 21 2 m 950 SH EFFI E LD DR M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 El 1 0 3GCUKRECOGG208307 Statefarm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 0620817SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L El ®N 2 G) ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) V N U1 m m 5 / J FOR DAMAGED AREA(S) FRONT TTLOiE EDCRasH 5 NAME(LAST,FIRST,M) Castaneda Castillo,YurgehS,Y. 0 mo lday 1 9 9 8 Volkswagen Jetta 2006 00-NONE ®' _1 ❑ ® 2 a 13-UNDERCARRIAGE 10i ©Ii s FIRE ❑ ® U2 C Xi c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a` 1802 WHITNEY DR F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POEH FIRSNT T COONTACT 11 r. . 6 ' .5 •ClrOveMe See Sidebar ® U1 H Hanover Park IL 60110 0 ET73971 IL 2025 REAR 0 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)457-0321 NIA IL D 0 3VWSF81 K66M737776 First Chicago Insurance C ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Rivero Izarra,Yoiber, D. ILS97863400 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°®NR 903 LAVOI E AVE, ELG I N . IL.60120 (872)400-1028 U1 = (UNIT' (SEAT) ;DOB) ISEX) (SAFT) (AIR) )INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)1ITELEPHONE I (EMS) (HOSPITAL) n I I - U2 996 1— m /• - #OCCS D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 09/20 /2024 02 15 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 1 2 0 2 06 ! / 0 PM ❑Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 7 Q CO 11 1 ARREST NAME / / El PM SLMT o U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility N AM 20 T 2 ❑ ARREST NAME 09/20 /2024 03 00 ®PM ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 0 AM Workers present? 0 Y 20 1526-Walsh.Jacob 701 / ElPM ®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 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C '. ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or n S ; l I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 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 • CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, r - DO ILCC NO. m U N XI , Source of above Z • . ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations MCS)violation contribute to the crash? O ❑ 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 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 0 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 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