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HomeMy WebLinkAbout2024-00061881 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II 1111111111111101111111111111111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003574341 u, 1 uz 1 3 4 1 u,16 U2 1 ut 1 U2 1 U1 99 U2 1 1 10 Ut 1 U2 3 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500El NOT ON S®ON SCENE • 3 VEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061881 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 11 ROYAL BLVD ❑ Elgin RELATED ®Y ❑N 09 27 2024 11'02 ®AM ❑YES ®NO U1 PRIVATE mo /day/yr El PM FLOW CONDITION m FT/MI N E S W N MCLEAN ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑say ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0 9 / 2 2 /1 9 3 9 FOR DAMAGEDAREA(S) FRONT TOWED Ut .Carl, M. Mazda 3 2005 00-NONE ®i 12I , DUE TO CRASH 0 ® E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 19 I 2 1 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) U2 3 < SYSTEM IN ENGAGED 15-OTHER 9 >I6-TOP 3 DISTRACTED ® 0 m 80 KINGSPORT DR M / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'DislractlonValue 6 ALGN - r CITY PLATE NO. STATE YEAR POINT OF !1 6 ii- COMe VEH ❑ ® 1 O JM1 BK323X51274495 USAA ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 03334 99 69G 7101 7 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU _° ❑Y ®N 2 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / 8 / FOR DAMAGED AREA(S) FRONT TOWED 5 NAME(LAST,FIRST,M) Gutierrez,Andres 0 6 1day 1 9$5 Ford F550 2019 oo-NONE Q' 12 ❑ 21 14 -I 13-UNDER CARRIAGE 10) j Y FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 a` 150 DEXTER CT M ❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN •Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 11 7.'1 6 5 Clr vesVSee Sidebar ® Utto C H ELGIN IL 60120 0 M220645 IL 2025 " • 0 I� M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)450-3866 G362-0008-5173 IL A 7 1 FDOX5HT6KEC36452 Charter Oak Fire Ins Comp ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I City of Elgin 8109160P901 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N El 150 DEXTER CT. ELGIN . IL.60120 (847)931-6100 Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)i(ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL) n -I I U2 996 r m - #OCCS y /• / Ut 1 73 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 09/27 /2024 11 02 ❑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: Ut 3 C) T 2 ID 40 17 ! / 0 PM ElConstruction a N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 8 AM ❑Maintenance uz Q 1 CO11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 30 2 0 ARREST NAME i / ptil ❑Unknown work zone type Ut 7 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 273-Tucker,Craig 500 - i / Q PM Workers present? ®N U2 30 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 r_.._r____ ; ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D n a7na..nreiMe 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer -< combination) or , ' I ! INDICATE NORTH 7:1 ' I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I I d i -` ` r r r (example.shuttle or charter bus)-or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 ---- ----� . l' } } transporting employees in the course of their employment(example employee M tr n 03 �____A____: . , ' i r i 4a suosedrordesgnatedto rransportbetween9and 15rpassengers,indudingthedriver, N I err I for direct compensation(example:large van used for specific purpose).or O . xvevao.aver.d uNmi a ` . 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m 7 placarding(example placards will be displayed on the vehicle) 71 eJsvn,r+eroa \ r ' CARRIER NAME Z ' 1 I ii I t ADDRESS To N N ?Jot Stele • CITY/STATE/ZIP I I 1. 1. 1. - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. Not in Comm./Other r , USDOT NO. ILCC NO. , 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 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 Gray White • - 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