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HomeMy WebLinkAbout2024-00061248 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III )III IIIIIII II 11111111111 IIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003569050 u, 1 U2 1 2 4 2 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500El NOT ON S®ON SCENE • 2 VEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2O24-00061248 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 't'I HILL AVE Elgin ❑ RELATED ®Y 0 N 09 24 2024 03:56 ❑AM ❑YES ®No u1 .< PRIVATE mo l day I yr ®PM FLOW CONDITION m FT/MI N E S W ADDISON ST 'COUNTY PROPERTY El Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ❑ WITH VEHICLES INVLD El STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) FRONT TOWED U1 .J EAN N ETTE,C. mo day yr z 1 1 / 2 7 /1 9 7 1 Honda Odyssey 2011 00-NONE QO.,0DUE TO CRASH ❑ 13-UNDERCARRIAGE FIRE ❑ ® �� 2 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) z DISTRACTED ® 0 U2 m 253 N LIBERTY ST F ❑Y ONE❑LINKVEH. O SYSTM AT CRASH 0D 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 5 ALGN = THER r CITY PLATE NO. STATE YEAR POINT OF 6 . 4 COM VEH ❑ El O jL FIRST CONTACT 11 7_ .; 6-::.5 ^Yves,See Sidebar U1 5FNRL5H64BB058640 GEICO ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR rn PATINO.JULIAN 6148512103 2 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > L RESPONDER y°®EN 253 N LIBERTY ST. ELGIN . IL.60120 (847)840-9139 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) Fernandez. Daniel 0 mo lday 2 0 0 1 Lexus IS250 2017 00-NONE 1t' 1'D 0 ® 2 Xi yr 13-UNDER CARRIAGE 10 j ©1' s FIRE ❑ ® U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) a 427 FU LTO N ST M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN ^Oistracllon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 7.,I—6 .5 COM•U VEH Sidebar 21 U1to C H Elgin IL 60120 0 dd71862 IL REAR 0fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)305-7606 F655-1600-1201 IL 0 JTHCK262375010190 PROGRESSIVE ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 981405220 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER® Same U1 = (UNITE i SEAT) ;DOB' ISEXI ISAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'/{ADDRESS)+I TELEPHONE) (EMS) (HOSPITAL) 1 6 03 /04/2014 M 2 4 0 1 0 MANOLO O. PATINO-DYSON/253 N LIBERTY ST,ELGIN.IL.60120 Refused 996 m uz m / I #occs y • / / U1 2 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 1 91 ,4/ /024 03 56 ®pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 7 T 2 ❑ 23 2 ! / 0 PM El Construction * 1 rr^A 3 ❑ ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q ARREST NAME DYSON.J EAN N ETTE.C. 11-1204-B 456-412 / / ❑PM SLMT 21 11 1 0 Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N ❑ ❑ SECTION CITATION NO. AM 25 2 0 ARREST NAME 9/ /4/ /024 03 56 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 25 456-Romalo,Carmine 301 - 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. r 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI 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 n S ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 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 placarding(example placards will be displayed on the vehicle) 11 T. . ` 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 0 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID 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 0 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 White Black - 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE