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HomeMy WebLinkAbout2024-00061557 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III III lull 11111111111 IIIIIII 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003566433 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 5 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00061557 VENT ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 SUMMIT ST ❑Elgin RELATED ®Y ❑N 09 26 2024 05:54 ®AM ❑YES ®NO U1 ,•< PRIVATE mo l day I yr El PM FLOW CONDITION m FT/MI N E S W HILL AVE 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR 0 SLOW 1 U) El 'WITH VEHICLES INVLD El STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EOUES 0 NW 0 NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGED AREA(S) FRONT TOWED Ut O ,J. 1 2 / 0 4 J 1 9 5 2 Hyundai Elantra 2018 00-NONE 0' 0..0 DUE TO CRASH ® ❑ E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE El SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED El ® U2 4 m 452 AN N ST M ❑Y ®SNEM El UNK EINH. 0 AT CRASHD 99-UUNKNOWN THER 9 16-TOP 3 ,Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT •OF 8 i j 6 4 COM VEH 0 ® 1 n FIRST CONTACT 12 7_ •I- ..5 ^Yves,See Sidebar U1 O Z KMHDO4LBSJU719594 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 983249431 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU X L ❑Y ®N 2 t7 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) MOW TOWED Y N 5 NAME(LAST,FIRST,M) BRACH, FREDERICK, R. 0 8 lda1 9 8 8 Kia Motors Col�orento 2011 00-NONE O 1° 1 DUE TOCRASH 0 2 XI v 13-UNDER CARRIAGE I ©I I_2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ❑ ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 X a 407 BERKLEY PL M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN II •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE Na STATE YEAR POF FIRST CNT ONTACT 11 7_'1 6 1_S G•IOMeeVSee Sidebar ® U1 07 ZStreamwood IL 60107 0 DG54775 IL 2025 I 0 PI M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)951-1135 B620-2568-8232 IL D 0 SXYKT3A13BG095739 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 9 Marple.James. E. 2286656SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°®NR 407 BERKLEY PL.Streamwood. IL.60107 U1 = (UNIT( (SEAT) (DOB( (SEX) ISAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE( (EMS) (HOSPITAL) n I I U2 996 r 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 ® 1 1 4 9/ /6/ /024 05 55 ❑pM in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1 a 2 0 2 99 ! / ❑PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q ARREST NAME Lara. Francisco.J. 11-901-A 495000416 / / ❑PM SLMT 1 ® 11 4 0 Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N SECTION CITATION NO. AM 35 2 0 ARREST NAME 9/ /6/ /024 06 30 El pm0 Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID, COURT DATE TIME ❑qM Workers present? El Y 35 495-Sjodir.Jacob 201 275-Engelke 10 / 15/2024 01 30 0 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 ; _� } 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 1 i ; I 0 combination) or -I INDICATE NORTH '—I [.... BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C XI ', ', i I -! ` r r r (example'.shuttle or charter bus)-or C amir'rsreee 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----;-----% i -t t r - i transporting employees in the course of their employment(example.employee M ueurn transporter-usually a van type vehicle or passenger car).or w i r , 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 L_____-____; i i r 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m unmi placarding(example placards will be displayed on the vehicle) 7/ l It t r rCARRIER NAME Z ' I ADDRESS 0 N CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. C , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? ❑ 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 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black Maroon u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage 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 ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE