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HomeMy WebLinkAbout2024-00061464 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III HI III ll II 11111111111 110111011111101111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00356E426 u, 9 uz 1 1 1 2 U, 9 U2 1 U199 U2 1 U1 99 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 1 [23 NOT ON VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061464 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 VINE ST ❑Elgin RELATED ®Y 0" 09 22 2024 03:01 ❑AM ❑YES ®NO U1 .< PRIVATE mo /day/yr ®PM FLOW CONDITION m ^,Oi1� O 'COUNTY PROPERTY El M N DOORING ❑y #OF MOTOR 0 SLOW 1 U) 02 CJ/MI N E S W Locust St 'WITH VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ® N Y ❑ PEDALCYCUST®N ® FREE FLOW # LNS 0 D4 DRIVER 0 PARKED ❑ORNERLESS ❑ FED 0 PEDAL ❑EOUES 0 NW 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FRONT TOWED U, O .0. Unknown Unknown DO-NONE 11 12 i' , DUE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE 10) 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER 9 15-TOP 3DISTRACTED 0 ® U2 O m r ❑Y ❑N ❑UNK VEH. AT CRASH 99-POINT UNKNOWN Distraction Value ALGN s {I ii 4 V 0 ® OF CITY PLATE NO. STATE YEAR { 6 COM ER1 w I- ID VIN INSURANCE CO. EXPIRED 1 o UNK UNK ❑Y ❑N U2 LI m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Ya r Same UNK 2 I- o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU X L ❑Y ® Same" 99 G-) m 0 DRIVER ® PARKED 0 CRNERLESS 0 PED ❑PEDAL 0 EQUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED —I NAME(LAST,FIRST,M) mo day yr Mitsubishi Mirage 2015 00-NONE tt` 12 '_1 DUE TO CRASH ❑ ® 2 a 13-UNDER CARRIAGE 10 j . s FIRE ❑ MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED O 15-OTHER 9 75-TOP 3 0 ® SPDR n ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value U1 0 - POINT OF 8 j li 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH 0 ® C 1— FIRST CONTACT 7 O7 .I 5 5 •IfYes,See Sidebar Z747568 IL 2025 REAR O fn, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ML32A3HJ2FH056829 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Rodriguez Marin.Jonathan 1667417-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 121 VINE ST. ELG I N . I L.60123 (224)402-3250 U1 = (UNIT (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)HADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 r m /• / - #OCCS D / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 18 1 09/25 /2024 05 01 ®pm in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: Ut 1 C) T 2 El 99 ! / 0 PM El Construction * N t 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 0 AM El Maintenance U2 8 Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 30 2 El ARREST NAME / / ptil ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 559-Maldonado. Daniela 701 334-Fries / / ❑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. _ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS Not To Scale I D r_.._r____; ; r A CMV is defined as any motor vehicle used to transport passengers or property and. Z 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z r } 1 YYro7St ; ; combination) or INDICATE NORTH Z�1 u • BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ', ', { N -! ` r r r (example'.shuttle or charter bus)-or 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----� -! } } } transporting employees in the course of their employment(example.employee transporter-usually a van type vehicle or passenger car) or w �____A____: : i , ® : : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose) or O i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m placarding(example placards will be isplayed on the vehicle) CARRIER NAME z t ADDRESS '� o N O CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. m , Source of above Z . 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 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 D 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 - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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