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HomeMy WebLinkAbout2024-00061962 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III I IIIIIII II 11111111111 110111111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003569053 u, 1 U21 1 1 1 U116 U2 1 U, 1 U2 1 Ut 1 U2 1 3 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061962 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT N STATE ST ® ❑ Elgin RELATED ❑Y CON 09 27 2024 05:18 ❑AM ❑YES ®No u1 .•< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W WING ST 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR El SLOW 1 N El 'WITH VEHICLES INVLD ❑ STOPPED U2 -I ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑NDv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 0 5FOR DAMAGEDAREA(S) 2007 00-NONE Feaa TOWED Ut O /�DUE TO CRASH NAME(LAST,FIRST,M) ,Juan mo / day J 0 0 1 BMW 3TI yr 0 O O El ❑ 3 13-UNDERCARRIAGE FIRE ❑ 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 El U2 4 m 602 JAY ST 1 M ❑Y ®SNEM El UNK VINEH. O AET CRASHD 0 99-UUNKNOWN THER 9 16-TOP 3 jEl,Distraction Value 9 ALGN = W. CITY PLATE NO. STATE YEAR POINT OF 8 4 COM VEH 0 1 0 FIRST CONTACT 12 7_.; 6--:_.5 •Yves,See Sidebar U1 Z WBAVA33537KX74606 American Allianca ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Same I LAA 0948797 01 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU 73 L ❑Y ❑N 2 0®DRIVER ❑ PARKED 0 CRNERLESS 0 PED ❑PEDAL ❑EDUCE 0 KW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m 2 / J FOR DAMAGED AREA(S) Fi20 IT TOWED Y N NAME(LAST,FIRST,M) Risch, Ryan 0 mo 0 8 2 0 0 3 Chevrolet Equinox 2018 00-NONE +c t 12 s Re o CRASH ❑ ® day yr ❑ U2 2 C v 13-UNDER CARRIAGE , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPUR n a 542 ENGLISH LN M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value POINT 1 4 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST OCOM VEH ❑ ® U1 CONTACT 6 7_t O,' byes,See Sidebar Z Winthrop Harbor IL 60096 B MV610B WI 2024 F>F O n TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)204-4706 R200-7360-3039 IL D Travelers ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Carmax 606729458 203 1 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 3320 ODYSSEY CT- Naperville- IL-60563 (847)839-8000 Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/)ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 1- m - '#OCCS > / / 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 1 91 /71 /024 05 18 ®pM in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5 2 0 28 18 91 /71 /024 05 55 ®PM ❑Construction * N T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 El 11 • 1 ARREST NAME Medina Nicanor,Juan 11-601-Ax 487000487 91 /71 /024 06 00 ®PM SLMT p U 0 CITATIONS ISSUED 0 PENDING • SECTION CITATION NO. ' ROAD CLEARANCE TIME < ❑Utility p N AM 35 2 0 ARREST NAME 91 /71 /024 8 pM ❑Unknown work zone type U1 T 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 35 487-Heal, Kayla 501 - 11 i 12/2024 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 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 r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! 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 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 ' i 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 • CITY/STATE/ZIP O , , . - 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 . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 73 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 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 Maroon White u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO- Other/Owners Residence 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