HomeMy WebLinkAbout2024-00061819 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III I IIIIIII II 11111111111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO3564C45
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 2
El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00061819 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
PROSPECT BLVD ® ❑ :14 ®
Elgin RELATED ®Y ❑N 09 27 2024 06AM ❑YES ®No u1 ,•<
PRIVATE mo /day/yr El PM FLOW CONDITION m
FTJMI N E S W RIVER
) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER 0 PARKED 0 DRNERLESS ❑ PED 0 PEDAL 0 EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 9 / 0 3 /1 9 5 8 FOR DAMAGED AREA(S) .FRONT TOWED U1
.James.C. Mercedes-Ber�550 2015 00-NONE 11 , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr Q
13-UNDERCARRIAGE 10 I• 2 FIRE 0
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m
458 WING PARK BLVD M SY❑Y ❑SNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16-TOP 3 .Distraction Value ALGN I
r CITY PLATE NO. STATE YEAR POINT OF 8 116 I( COM VEH 0 ® 1 n
m FIRST CONTACT 12 7 tl�_5 'If Yes,See Sidebar U1 0
Z
WDDUG8FB9FA158043 MIC general insurance ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
a Same 2015210938 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
>. RESPONDER Same VEHU
L ❑Y ®N 2 G1
®DRIVER 0 PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 Nay ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m
m 7 / J FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Marzullo,Anthony. D. 0mo lday yr 1 9 6 7 El Dorado MfgE2ktder 2008 00-NONE 1ti 12 1 DUE
TOCRASH O 0 U2 29 xi
I', 13-UNDER CARRIAGE I:_ZC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 IN SPUR C)
a` 636 ARLINGTON LN M
SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 0 X
❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF
FIRST CNT ONTACT 1 O 7_'1 a 1_5 C•IOMesVSee Sidebar ® U1
to
ZSOUTH ELGIN IL 60177 0 M182725 IL 2024 0 n
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(312)446-8678 M624-0046-7196 IL B 7 1N9MNAC648C084066 self insured ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST.M) POLICY NUMBER 1 I
PACE SUBURBAN BUS self insured BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
0 YRESPONDER 550 ALGONQUIN RD.60110 (312)446-8678 U1 =
(UNITE i SEAT) (DOBi ISEXI ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)HADDRESS(1(TELEPHONE) (EMSI (HOSPITAL)
2 6 05 /1 2/1960 M 1 3 0 1 0 Miguel C. Garcia/914 BROOK ST.ELGIN.IL.60120 996 r
(847)695-3244 , U2 m
/ / #OCCS D
/ / UI 1 m
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N Mil 4 09/27 /2024 06 14 ❑pM in a Work Zone? ElN DIRP co
IN
PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T 2 0 23 99
! / 0 PM El Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
ARREST NAME Schock,James,C. 11-901-A 1522-180 / / ❑PM SLMT
1 ® '11 4 0 Utility
p u 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8 AM 30
2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AAA Workers present? ❑Y 30
1522-Velazquez. Noeli 102 - 10 /21 /2024 01 30 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 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 Hated to trans rt between 9 and 15 assen ers including the dr ver,
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
. O
• CITY/STATE/ZIP 0
, ,
MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
C
r-----.-----, r r r r r----, i
r - DO ILCC NO. m
U N XI
, Source of above Z
own tank)? ❑ Yes ❑ No ❑ Unknowr
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
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
Black BlueEn
-
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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO:
DUE TO ❑ Other/Unknown VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE