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HomeMy WebLinkAbout2024-00061499 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets ii ii III Olfi Ifi IIIlIII 11111111 11111 1111111111 11111111 Ill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY n03565193! u, 1 U2 1 1 1 U1 9 U2 1 U, 1 U2 UI 1 U2 1 1 9 U123 U221 *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 1 0 NOT ON S VEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061499 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT DUNDEE AVE ® ❑ Elgin RELATED ❑Y coN 09 25 2024 06_28 ❑AM ❑YES ®No ut --‹ PRIVATE mo l day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y 0 N DOORING ❑Y #OF MOTOR ®SLOW 1 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD IDSTOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N [] FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES 0 SIN ❑Rcv ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 0 9 / 1 3 /1 9 9 0 Honda Odyssey 2010 00-NONE ©, 12 , DUEFIRE TO CRASH p21 NAME(LAST,FIRST,M) mo day yr ,3-UNDER CARRIAGE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 l U2 0 m 2025 TO R I N O DR F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 09 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 6 4 COM VEH 0 ® 1 O ra 5FNRL3H67AB089366 Country Financial ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Ahmed. Rashid P010446323 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER o RESPONDER y°®EN 2025 TORINO DR. ELGIN - IL,60123 (847)710-4389 VEHU G1 m 0 DRIVER ® PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EOUES 0 RIAV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Toyota Corolla 2014 00-NONE it 12 I._� DUE To CRASH ❑ ® 1 71 a 13-UNDER CARRIAGE to i I 2 FIRE El MI U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3O 0 ® SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 O•Distraction Value 9 U1 0 - HCITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RST COONTACT F 5 7_ 6 • OS Clrve6VSee Sidebar❑ ® C DT38142 I L 2025 REAR 0 n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2T1 BURHE8EC213891 Statefarm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Baeza. Martin 2142890SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ONDE 0 Y NR 48 HEMLOCK CT A. ELGIN - IL,60120 (224)508-3059 Ut = (UNIT (SEAT) (DOB) ISEXI ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I{ADDRESS)/iTELEPHONE) (EMS) (HOSPITAL) n I I U2 996 ,— m / / - #OcCS y / /• U1 1 73 / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME 0 AM Did crash occur ❑Y U2 Z N ® 18 5 09/25 /2024 06 28 ®pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM If YES check one below: Ut 4 T 2 0 30 99 ! / 0 PM ❑Construction * N 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q ® 11 5 ARREST NAME I I ❑PM SLMT o UCITATIONS ISSUEDPENDING ROAD CLEARANCE TIME ' 0 Utility o N 0 0 SECTION CITATION NO. AM 10 2 0 ARREST NAME 09/25 /2024 06 28 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 10 1500-Chew, Marie 301 334-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. _ 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. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i combination) or INDICATE NORTH XI ^ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', ', i / 'ir` -! ` r r r (example.shuttle or charter bus)-or 0 NI r L-___a___-. 4 I J / } t porongemployeeslinthecouseaoftheirempayment(example�emapbyeerie i 3 Is f transporter-usually a van type vehicle or passenger car).or w �____A____: : , S° mra.anwe i r i 4 Is used or designated to transport between9and 15passengers,including the driver, C I ) / ) for direct compensation(example:large van used for specific purpose).or O --e i j Not To Scale po any (HAZMAT) a m y 5 Is any vehicle used to transport hazardous materialthat requires placarding(example placards will be displayed on the vehicle) 71 . / Unit T. CARRIER NAME Z • ' / _: .. ADDRESS To 0f i - Unit1 • 0CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. m XI , Source of above Z . 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? 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 5 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 D 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 Blue-Light 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE