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HomeMy WebLinkAbout2024-00061299 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 M llOI �� Ill HID II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035.3099' u, 1 u211 3 4 2 u, 4 U2 1 u, 1 u2 1 u,99 U299 5 13 u, 15 U211 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 4 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 2024I 2024-00061299 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1 ® ❑ RELATED ®Y 0 N 09 24 2024 ❑AM ❑YES N NO U1 S RANDALL RD Elgin09:16 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION ITl FT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIIv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 n T TOWED U1 O MATEOS-J I M EN EZ.CESAR, I. Nissan 370Z 2016 00-NONE ©, • 12 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 i . 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 8 rn M 2 SYSTM 8 ❑Y ONE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i1 6 i. 4 COM VEH 0 0 1 C) ELGIN I L 60123 0 1 0 FIRST CONTACT 15 t RE4R-O •II Yes.See Sidebar U1 0 Z DA84220 IL 2025 TELEPHONE IL D J N 1 AZ4EH 1 G M931385 ALLSTATE ❑Y ® r 1N U2 R 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 811105365 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 3 2 0 m �{ DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL ❑EWES O Nuv 0 NOV 0 Dv CIRCLE NUMBER(S) U1 !1 9 5 7 Honda Accord 2017 oo-NONE „ 12M , DUE TO CRASH rg ❑ 2 x o - 13-UNDER CARRIAGE FIRE ID N U2 c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 ❑Y ®N ElUNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value 9 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I 6 i, 4 COM VEH 0 N u1 CO FIRST CONTACT 11 O1_i _s •If Yes.See Sidebar C ELGIN IL 60124 B 1 0 MSA20 IL 2025 I 3 Cl) IL D 1 HGCR3F91 HA019772 STATE FARM ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same 0126928-SPF-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER ® 3 U1 = (UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2Z N 1 ® 11 4 91 !4/ l024 09 16 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � Ft 2 ❑ 50 11 91 !41 ,024 09 18 ®PM ❑Construction <w O ❑ gi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 3 ❑AM 0 Maintenance U2 -a, ARREST NAME MATEOS-J I M EN EZ,CESAR, I. 11-1427-H- 302-000709 91 ,41 ,024 09 20 ®PM SLMT 1 ® 11 4 •N CITATIONS ISSUED 0 PENDING o uSECTION CITATION NO. ROAD CLEARANCE TIME AM, ElUtilit y t 2 El ARREST NAME MATEOS-J I M EN EZ,CESAR, I. 11-709-A 302-000710 91 ,4/ ,024 10 00 0 PM El Unknown work zone type u1 50 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50 302-Snow, Kevin 801 393-Gutierrez 10 , 15,2024 01 30 ❑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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; 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 truck trailer -< i- }____r____1 I I I I combination)or INDICATE NORTH p1 ti BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I II I IL. - } (example:shuttle or charter bus):or 0 r I I i I I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O }_--_A____I 00.1•11,�, BIN* _ transportingemployeesg ployment(example:employee 73 } } } in the course of their employment transporter-usually a van type vehicle or passenger car):or co i. }-----}----; - - , - } } 1. •4. Is used or designated to transport between 9 and 1 passen rs,including the driver, C W for direct compensation(example:large van used fors specific purpose):or O ' L____a____. 1 _ i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires rn placarding(example:placards will be displayed on the vehicle). ;p _ — 2). + CARRIER NAME ' ADDRESS 0 Not To Scale i I I "' I I > I II I ti I I CITY/STATE/ZIP n I I I I - MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Gout. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® 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 DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE