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HomeMy WebLinkAbout2024-00061235 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III HI IIII lull 11111111111 110111111111 1111 Ill I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00356E151 u, 1 U2 1 1 1 2 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 1 16 U1 23 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061235 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'F'I FRANKLIN ST ®gin ❑ RELATED ❑Y co" 09 24 2024 02'39 ❑AM El ®No u1 .< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W N GIFFORD ) Kane HIT&RUN El Y ® " PEDALCYCUST®N [] FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O NAME(LAST,FIRST,M) ,O. D 9 / 1 mo tl 5 J 1 9 5 D General MotorSi nq 2010 ®-NONE 11 1s , DUE TO CRASH ❑ ® - E 13-UNDER CARRIAGE 10) 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 2 m 271 N GIFFORD ST M SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0D 99-U 15-UNKNOWN 9 16-TOP 3 1.Distraction Value 9 ALGN = THER 11.' . PLATE NO. STATE YEAR POINT OF 8 it 6 ) 4 COM VEH ❑ ® 1 n F FIRST CONTACT 00 7__t 0 "If Yes,See Sidebar U1 0 Z 3GTRCTEA4AG287616 NATIONWIDE ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Same 9112J009662 2 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU ❑Y ®" 2 G) ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 NOV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) Fi20 IT TOWED Y N n NAME(LAST,FIRST,M) Palomar-Fuentes,Susana 0 0 ld y 1 9 y 6 Jeep(after 19BS nd Cherokee 2015 00-NONE 11: 12 1 ETOCRASH O ® U2 2 v 13-UNDER CARRIAGE I._Z FIRE C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® SPDR n a` 125 HINSDELL PL 1 F SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N ElUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR IST CNT OONTACT 1 O 7__'I 6 6 C•IOMeeVSee SidebaEH ❑ ® U1 to H C ELGIN IL 60120 0 EM33963 IL 2025 0 99) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)806-5305 IL 0 1C4RJFAG2FC939970 AMERICAN ALLIANCE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same ILAA069172402 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y N El R Same Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m - - #OCCS y / /• U1 11* 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur IDY U2 Z N ® 11 1 9/ /4/ ;024 02 39 ®pm in a Work Zone? ®N 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 1 C) T 2 El 30 14 ! / 0 PM ❑Construction * N 3 ❑ igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z ❑AM El Maintenance U2 •® 11 1 ARREST NAME Quick, David,0. 11-1402 456-411(w) / / ❑PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility o N ❑ ❑ SECTION CITATION NO. AM 25 2 0 ARREST NAME 9/ /4/ /024 02 39 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 456-Romalo,Carmine 301 - I / Q PM Workers present? ®N U2 25 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. r 0IF 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or —I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------t-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O 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) .Z1 I. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, i - DO ILCC NO. m U N XI , Source of above Z . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No P3 73 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 ❑ No - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m X1 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 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z White SilverEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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