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HomeMy WebLinkAbout2024-00061254 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111IIIIIIIIII 1111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003565182* u, 1 U2 1 1 1 2 U1 7 U299 U, 1 U2 1 U,99 Uz 99 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061254 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I RT20 EB ®gin El ❑Y coN 09 24 2024 04_24 ❑AM ❑YES ®NO U1 ,< • PRIVATE mo /day I yr ®PM FLOW CONDITION m Ell 0�,/MI N E S© S State St 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 I&oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES ❑Nuv ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) FRONT TOWED Ut 0 , Daniel, E. 1 1 / 1 3 /2 0 0 0 Hyundai Elantra 2016 00-NONE Q..O.,Dt DUE TO CRASH ❑ vi NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 ❑ 0 U2 2 < DISTRACTED123 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 946 SEMINOLE DR 1 M ❑Y ElN ❑UNK VEH. 0 ATCRASH 99-UNKNOWN DislractlonValue 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH ❑ El 1 O iL FIRST CONTACT 12 .; 6-:_.5 ^Yves,See Sidebar 7 U1 Z SNPDH4AE1 GH703891 American Alliance ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn a Silano Velasque.Cesar-A. I LAA08941 1000 2 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER .5 o vONDE J N 648 E LINCOLN ST. Palatine. IL.60074 (307)761-4253 VEHU > ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Florez Camacho,Astrid-J. mo �ay 1 9 9 0 yr Hyundai Elantra 2011 oo-NONE 1t 1$ '1 DUETOCRASH ❑ ® 2 Xi v 13-UNDER CARRIAGE 10 j I! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED D ❑ SPOR C) E 1033 HELEN LN F SYSTEM IN Q ENGAGED Q 15-OTHER 9 16-TOP 3 9 4 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value NI CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSNT T CONTACT 6 O7 8 1 a--�5 C•lOkes gee Sidebar❑ El U1to C Z Shaumburg IL 60193 0 DJ28434 IL 2024 R 4 CI) D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (331)356-6926 F462-0109-0667 IL D 0 KMHDB8AE7BUO95474 Unique Insurance Company ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same I LP2813697 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPOND ElN Same Ut = (UNIT) (SEAT) ;DOBi ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS1 (HOSPITAL) I I - uz 996 1- m / _ #OCCS D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ®Y U2 Z N ® 11 1 09/24 /2024 04 33 ®pm in a Work Zone? ❑N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 C) T 2 0 28 03 ! / 0 PM ®Construction * c' 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 AM ❑Maintenance uz Q ® 11 3 ARREST NAME / / El PM SLMT o uCITATIONS ISSUED PENDING ROAD CLEARANCE TIME 0 Utility 0 ❑ SECTION CITATION NO. p N AM 45 2 0 ARREST NAME 09/24 /2024 04 52 ®PM ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ®AM Workers present? ❑Y 45 1525-Nava.Oscar 701 - 10 /22/2024 09 00 p 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 j _ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; I _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r { { { t ; combination) or '1 gq pst INDICATE NORTH 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I d i -` ` r r r (example.shuttle or charter bus)-or 0 X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.----.....---% -i } - i transporting employees in the course of their employment(example.employee M tr -usually a van vehicle or ca el ii r i 4a Is usedror des gnated to trransport between 9 agdr 15rpassengers,including the driver, u) for direct compensation(example:large van used for specific purpose).or O L---- -----+ 4 + .. Not To Scale f - } } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z t ADDRESS 0 Unit 2 N . _ • CITY/STATE/ZIP 2 , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. Unit� m m , Source of above 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 ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Bronze Gray - 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- 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE