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HomeMy WebLinkAbout2024-00061448 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 11111111111 IIIIIIIIIIIIIIIIIIIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003565194. u, 1 U2 1 1 1 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 Ut 1 U2 11 *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-$1.500 ®ON SCENE • 2 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061448 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I VILLA ST ®gin El ®'' 0 N 09 25 2024 03:23 ❑AM El ®No u1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W HAVERMAN ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑RDV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 1 1 Hundai Accent 2013 FOR DAMAGED AREA(S)00-NONE FRONT TOWED U1 NAME(LAST,FIRST,M) ,S. mo / day J yr y 0 Q O DUE TO CRASH ❑ 13-UNDER CARRIAGE 21 FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 10 U2 2 m 399 SILVER ST F ❑Y ®S NE❑UNK VEH. O SYTM AT CRASH 0D 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = THER r CITY PLATE NO. STATE YEAR POINT OF 8 .FIRST CONTACT 12 7_71 6- • 4:_.5 •COM VEH ❑ El 0 m F Y Yes,See Sidebar U1 Z EL58504 Progressive ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 WAXLER, MATTHEW,T. 930572722 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > L RESPONDER y°®EN 399 SILVER ST, ELGIN , IL,60123 (630)217-0107 VEHU G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑soy 0 ov 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) Benitez Sanchez, Rober, D. lmo 3 1 9 8 6 Mazda Mazda 3 2011 oo-NONE it'10 12 11'_s DUE TO CRASH ❑❑ ® Uz 2 C c 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) E 517 VILLA ST M SYSEM Y ❑ ® T , IN 0 ENGAGED 0 ® 6 OTHER 9 1 -TOP 3 DUNK VEH. AT CRASH 99-UNKNOWN •OistractionValue 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & ) 4 COM VEH ❑ to F FIRST CONTACT 6 CI._�C61,)_p ® UIC •IfYee,SeeSidebar ELGIN IL 60120 0 EK88873 IL 2024 REAR M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)856-8241 B532-7248-6371 IL D 0 JM1 BL1 UFB1460477 Safeway Insutance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Florencio,Cortezano 3944944 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < PONDE DY UNR 1345 KINGSBURYCT, Hanover Park, IL.60133 (224)856-8241 U1 = (UNIT) (SEAT) (DOB) ISEX) ;SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) n I / U2 996 r m / - #OCCS D / /• U1 1 m Ito I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 11 1 9/ /5/ /024 03 23 ®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 7 C) T 2 ❑ 03 28 ! / 0 PM El Construction * N T 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 •CO 11 1 ARREST NAME Waxier, Madigan,S. 11-601 w485000306 / / El PM SLMT o U 0 CITATIONS ISSUED PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N B AM 30 2 ❑ ARREST NAME / / ppt ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 485-Quintana,Josue 302 334-Fries I / ❑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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I 0 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 truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or 'I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ I ', ! 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 . ` CARRIER NAME Z ' .. ADDRESS 0 N . O • CITY/STATE/ZIP 0 , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above 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? O ❑ 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 Form Number 0 m 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 >102 m m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Green 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