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HomeMy WebLinkAbout2024-00060393 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 OIl III )III IIIIIII II 11111111111 IIIIII Ill llfllfllflllil II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035561024 u, 1 U21 3 4 1 U, 1 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 2 0 NOT ON S VEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00060393 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 API SUMMIT ST ❑ Elgin RELATED ❑Y CON 09 20 2024 04'09 ❑AM ® ❑YES NO U1 ,< • PRIVATE mo /day I yr ®PM FLOW CONDITION m 0 /MI N E S ShadyOak ) PEDALCYCUST® 0 FREE FLOW # LNS 0 tg DRNER 0 PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / 2 4 /1 9 9 4 FOR DAMAGEDAREA(S) FRCNT TOWED Ut NAME(LAST,FIRST,M) Miguel. mo day yr © O . A. Chrysler Pacifica 2017 00-NONE , DUE TO CRASH El - E 13-UNDERCARRIAGE FIRE ❑ 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� z DISTRACTED 0 I� U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 255 SILVER CT M ❑Y El ❑UNK VEH. O ATCRASH O 99-UNKNOWN Distraction Value ALGN I r CITY PLATE NO. STATE YEAR POINT OF 7 8 . 4 COM VEH ❑ El 1 0 jL FIRST CONTACT 12 .i Q:_.5 •Yves,See Sidebar Ut Z 2C4RC1 BGXH R526801 Kemper ❑v ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 12RA000007355 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > >. RESPONDER Same VEHU73 L ❑Y ®N 2 G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 Nov ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N S NAME(LAST,FIRST,M) 0 8 Omo a 1 9 4 9 yr Can Am I 2020 00-NONE DUE TO CRASHXi Morehouse, Lonnie, B. �r ,2 D 0 2 v 13-UNDER CARRIAGE 101 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM ENGAGED O 15-OTHER 9 INVEH. O 16-TOP 3 0 a 820 CARNABY CT M ❑Y MIN ❑UNK AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 9 1 f 4 COM VEH 0 ® U1 to FIRST CONTACT 6 Q •bYes,See Sidebar NEAR C Z Schaumburg IL 60194 0 GA8424 MC 2025 0 rp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)312-0355 M620-5224-9219 IL D 2BXNBDD29RV000222 ALLSTATE ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 962079696 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < RESPONDER ❑ Same Ut = (UNIT) I SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/ITELEPHONEI (EMSi (HOSPITAL) 1 4 05 /1 6/1996 M 2 3 0 1 0 ARLIS E. CEFERINO RIVERA/440 FRANKLIN ST.Elgin.IL.60120 996 1— (224)468-5584 , U2 m 1 3 09 /24/1994 M 2 3 0 1 0 NATIVIDAD CEFERINO MORALRS/440 FRANKLIN ST-Elgin.IL.60120 #OCCS D (224)468-5584 _ / / ut 3 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 09/20 /2024 04 09 ®pm 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) ai T 2 0 11 1 28 99 ! J 0 PM 0 Construction * N 1 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 • Q ® 11 1 ARREST NAME Saban Atz. Miguel.A. 11-601 1535000076 / / El PM SLMT o U ®CITATIONS ISSUED 0 PENDING ROAD CLEARANCE TIME ' ❑Utility o NSECTION CITATION NO. AM 30 T 2 oil 1 ARREST NAME Saban Atz- Miguel.A. 6-101 1535000075 09/20 /2024 04 09 ®PM 0 Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? D Y 30 1535-Solis. Laura 202 - 10 /22/2024 01 30 0 PM IZI 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_ 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 Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer 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 } -( ', d i -` ` r r r (example.shuttle or charter bus)-or 0 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 i.----------% ( 111... porting employees in the cou se of their employment(example employeeNot Tb Soh ftra IInsporter-usua y a van type vehicle or passenger car).or �:_ A_ __: : i , : : : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N t for direct compensation(example.large van used for specific purpose).or O :____"-____; ; . , : } 15 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires j - placarding(example placards will be displayed on the vehicle) 11 t 2. — — — — — — — — CARRIER NAME Z ' 1 .. ADDRESS To 0I `� I I cn • • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , 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 Black 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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. DUE TO ❑ Other/Owners Residence VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE