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HomeMy WebLinkAbout2024-00061441 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi IIIIIII II 11111111111 1101110111110111111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XIO3566414 u, 1 U2 1 1 1 U116 U2 U, 1 U2 Ut 1 U2 1 6 Ut 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE • 7 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061441 VENT ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 7'1 BRAEBURN DR ® ❑ Elgin RELATED ❑Y CON 09 25 2024 03:03 ❑AM ❑YES ®No ut ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 0 I MI N E S W CenturyOaks ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS O tg ORNER ❑ PARKED 0 DRIVERLESS ❑ PEe ❑PEDAL ❑EDUES 0 ram ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED Ut NAME(LAST,FIRST,M) . Elizabeth Chevrolet Traverse 2013 00-NONE 1 1 O mo / day / yr ®i ©I 1 Dt1ETOCRASH El ❑ flit( 2 FIRE El ® < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m 1254 GREEN ACRES LN F ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 86-TOP 3 "OislractlonValue 5 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6• !1 6 II_4 COM VEH 0 EI 1 0 rA 1 G N KVLKD8DJ260052 Direct Auto NI" ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same PAI L001 069142 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED fi DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 Xi C c 13-UNDER CARRIAGE 10 t I 2 FIRE ❑ ❑ U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7.1I 61_5 CIOMe63eeSideba❑ ❑ C to H �� • Cl) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF73 EMS AGENCY I PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < OPOQNR Ut I (UNIT) I SEAT) IDOB) (SEX) i(SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) {EMS) (HOSPITAL) n 1 6 1 0 /05/2012 F 1 3 0 1 Maite Barboza/1254 GREEN ACRES LN.ELGIN,IL,60123 U2 m 1 5 05 /1 0/2015 F 1 3 0 1 Alexa Barboza/1254 GREEN ACRES LN-ELGIN-IL-60123 #OCCS D 1 4 04 /1 7/2014 F 1 3 0 1 Victoria Ocegueda/1254 GREEN ACRES LN.ELGIN.IL.60123 lit4 m D I I 0 EV MOST EVNT• LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 5 U46 School District Handicap parking lot sign 09,25 ,2024 03 03 ®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 ❑AMU1 1 2 0 1235 BRAEBURN DR ELGIN IL 60123 41 18 ! , ❑PM ❑Construction * ot 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIMEEl AM El Maintenance U2 Q ARREST NAME / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N 8AM 10 2 0 ARREST NAME , I ptil ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 3 0 ®AM Workers present? El Y 492-Gardrer. Mikaela 501 334-Fries 10 , 15/2024 09 00 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. 0_ IF 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 property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I 1 INDICATE NORTH combination) or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I d i -` ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 f.----.....---% J -i } i transporting employees in the course of their employment(example.employee M izasre roumaor. transporter-usually a van type vehicle or passenger car).or w i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N rp.r. for direct compensation(example:large van used for specific purpose).or O L____-L___-; i , . 3 -: i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI T. CARRIER NAME Z 0 t ADDRESS 0 , Not To Scale N • n CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. • , Source of above Z 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 A 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 Form Number 0 7a 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft N Gray - 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE