Loading...
HomeMy WebLinkAbout2024-00061413 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111111011111HH1111 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003574345 u1 1 U2 1 1 1 U116 U2 1 U17 3 U2 UI 1 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061413 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT MOUNTAIN ST Elgin ❑ RELATED ❑Y co" 09 25 2024 11.3g ®AM ❑YES ®No U1 .•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m 1102 5 /MI N E S W Highland Ave 'COUNTY PROPERTY ❑Y ®" DOORING ❑y #OF MOTOR ❑SLOW 15 co ® O g Cook HIT&RUN ❑Y ® " WITH N VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 / 0 7 /1 9 7 3 FOR DAMAGEDAREA(S) FRONT TOWED U1 . B. Chevrolet Malibu 2010 00-NONE 11 12 i' , DUE TO CRASH ❑ Vi NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m 151 DOUG LAS AVE M ❑Y ®SYSNEM❑UNK VEH. 0 AT CRASH 99-UNKNOWN THER 9 16-TOP 3 Distraction Value 5 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6 {Imjl 4 COMVEH ❑ ® 2 0 ~ 1G1ZB5EB1AF287736 No Proof ®v ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 1 99 9 Gomez.Juan. P. n!a 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER 426 MEADOW GREEN DR. Round Lake Beach. IL.60073 (630)998-3101 VEHU 0 ❑DRIVER ® PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 98 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N S Ford Explorer 2020 oo-NONE 1t' I'_1 DUE TO CRASH ❑ ® 6 NAME(LAST,FIRST,M) mo day yr 10 ©il z FIRE ❑ ® U2 C c 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPDR n ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value 6 U1 0 - POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® to H FIRST CONTACT 12 7. -6 • • 5 Irves,See Sidebar C MP18418 IL 2024 0 I;p M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FM5K8AW6LGB84210 Alliant Insurance ❑y ON RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 City of Elgin 8109160P901 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 150 DEXTER CT. ELGIN . IL.60120 (847)931-6100 U1 = (UNIT) i SEAT) (DOB) )SEX) )SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I{ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) 2 6 03 /28/1994 F 2 4 0 1 0 Jannett Diaz/980 CONGDON AVE 14,ELGIN.IL-60120 Refused 996 ,- (630)998-3101 , U2 m / / #OCCS D / / u1 1 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 18 1 09/25 /2024 11 33 ❑pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 5 T 2 ❑ 18 17 ❑AM ! , ❑PM 0 Construction * c' 1 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM ❑Maintenance U2 5 Q CO 11 1 ARREST NAME Diaz.Jannett 3-707 273-3615 / / El PM ❑Utility SLMT p U CI CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 30 2 ❑ ARREST NAME I / ptil ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? D Y 30 320-Cox.Jonathan 601 353-Duffy I , 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 r- -r--- 4 , 4 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r •• ; i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! i- ._ ' ' '. ', ' f ` 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------.-----• + + • : - -, 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 placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP O , , MOTOR CARR ID ❑ Interstate ElIntrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r•---, - DO ILCC NO. m U N XI , Source of above Z . GVVVR/GCWR ❑ <10,000 0 10,000-26,000 0 >26,000 Z Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard 0 4 digit UN NO. 1 digit Hazard class No 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% A ❑ Yes No ❑ Unknown 0 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 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Gray Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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