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HomeMy WebLinkAbout2024-00062404 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III II 0 lu II 1111111111111111111 � lllfllfl III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035;222r u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 4 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 El NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00062404 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 SUMMIT ST ®gin ID ®Y ❑N 09 29 2024 07:07 DAM ❑YES ®NO U1 ,•< PRIVATE mo l day I yr ®PM FLOW CONDITION m FT/MI N E S W WAVERLY ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES ❑SIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / 0 2 /1 9 9 9 FOR DAMAGEDAREA(S) FRONT TOWED U1 ,Aaron Nissan GT-R 2017 00-NONE 11 12 DUE TO CRASH 0 ® - E 13-UNDERCARRIAGE 101 , 2 FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 2 m 217 N G I FFO R D ST M ❑Y ®SNEM❑UNK VINEH. O AET CRASHD 0 99-UUNKNOWN THER 9 16-TOP 3 ,Distraction Value 9 ALGN = 1 CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii-4 COM VEH 0 El 1 0 jL FIRST CONTACT 7__, �_5 •If Yes,See Sidebar U1 Z JN1AR5EFOHM820459 State Farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 2121266SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 17 ' ®DRIVER ❑ PARKED 0 ERNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED n NAME(LAST,FIRST,M) Martinez.Jose. R. 0 mo8 day 1 9 yr8 4 Acura MDX 2010 00-NONE 'o) 12 Y RE o CRASH O ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPCA 0 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X a` 373 ST CHARLES ST M ❑Y El N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & iI 6 _ ®1, 4 COM VEH ❑ U1to F, FIRST CONTACT 7 Q. 5 •IfYes,See Sidebar ELGIN IL 60120 0 DU90046 IL 2024 9 c.n Z M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)310-8250 M635-4368-4240 _ 73 IL D 5J8TB1 H21AA003067 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 2337346SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y N El R Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME);(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - #OCCS > / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 1 91 ,91 /024 07 07 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 3 C) T 2 0 28 03 ! I 0 PM ElConstruction a N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q CO 11 1• ARREST NAME Madrigal,Aaron 11-601 W1504000394 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N B AM 30 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ El AM Workers present? ❑Y 30 1504 Real. Hilario 202 334-Fries , ❑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. , IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . 0 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z "--r----, , 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------.-----• + + • : - -, 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ 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 • . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No PJ 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 Purple Gray - 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