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HomeMy WebLinkAbout2024-00061811 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 11111111111 IIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003569�C4 u, 1 U2 1 2 4 1 U1 3 U2 1 U, 1 U2 1 Ut 1 U2 1 5 10 Ut 4 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 3 0 NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061811 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1 ADAMS ST ®gin ID ®Y ❑N 09 27 2024 04:44 ®AM ❑YES ®No u1 ,< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W S STATE ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR El SLOW 15 co ❑ 'WITH VEHICLES INVLD 0 STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EOUES 0 NW ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 . LUIS, F. 08 / 1 9 '1 9 7 1 Chevrolet Cruze 2014 00-NONE ®i 12I 1 DUE TO CRASH ElM — 3 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE IA 10 I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 3 m 477 STELLA ST M ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8• !1 6 ii 4 COM VEH 0 El 1 0 ra ~ 1 G 1 PC5SB1 E7341254 None ®Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Munoz. Eduardo None 1 I— t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER o RESPONDER 603 HAMPTON CIR. ELGIN . IL.60120 (847)468-7482 VEHU 0 ®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) FROM RASH Y N n NAME(LAST,FIRST,M) Soto_Antonia.S. lmo $ 1 9 8 8 Hyundai Veracruz 2011 00-NONE 1t` ,s 1 ❑ ® 2 Xi Xi I', 13-UNDER CARRIAGE 10 j z FIRE ❑ ® U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X a` 257 FRAN KLI N ST F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN II •Oistraclon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 7.'1 6 •5 C•IOMeS See SidebaH r ® U1 to ~ C ELGIN IL 60120 0 AT55383 IL 2025 Ra 0 Cn m TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (331)588-8695 S300-0178-8918 IL KM8NUDCC8BU147181 Unique Insurance Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 10 = Same I LP3303027 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YOND 181 N Same U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) / I U2 996 1- m • - #OCCS y / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ®Y U2 Z N ® 11 4 09/27 /2024 04 44 ❑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 22 13 ! / 0 PM in Construction * c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 CO 11 4 ARREST NAME MUNOZ. LUIS. F. 11-1204-8 340000114 / / ❑PM SLMT o u ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility NAM 30 2 0 ARREST NAME MUNOZ. LUIS, F. 3-707 340000115 r / 8 ptil El Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 340-Phillips. Kathryn 700 - 10 121 /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. 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 • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i. L ' ' '. ', ' 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------t-----• + + • : - -, 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 C r-----.-----, r r r r r•---, i - DO ILCC NO. m U N XI , Source of above Z . —I Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) 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 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 ❑ 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 CJ 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 Silver Blue - 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