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HomeMy WebLinkAbout2024-00062915 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III HI1 11 lull 11111111111111011111HH1110 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00357434r u, 1 U2 1 3 4 1 U199 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 10 Ut 4 U2 1 *P 0119* 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 1 EI NOT ON VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00062915 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 'IT ST CHARLES ST ® ❑ Elgin RELATED ®Y ❑N 10 02 2024 08:42 ®AM ❑YES ®No ut ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m Fri MI N E S W BLUFF CITY ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 ECUES 0 NW 0 NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 . L. 0 9 / 2 8 J 1 9 7 1 Volvo VNL 2016 00-NONE 1 12 1 DUE TO CRASH ❑ DEg a NAME(LAST,FIRST,M) ry• mo day yr 13-UNDERCARRIAGE 10l 2 FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ lid U2 m 6776 N 1150 W M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = &• 4 PLATE NO. STATE YEAR POINT OF !1 6 II_ COM VEH ❑ El 1 00 r' F 4V4NC9EJ2GN956178 Marsh USA LLC ❑Y ®N U2 m 49 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Landstar M HW TT307222 24 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER L RESPONDER Y Ei N 13410 SUTTON PARK DR .Jacksonville. FL.32224 (904)398-9400 VEHU > O ®Calves ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 21 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Rodriguez.Jose.S. lmoo day 1 yr 9 5 3 Toyota Tundra 2011 oo-NONE ;0 12 s FIREETocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �,,�DISTRACTED 0 IN SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-T�®• 0 X a` ❑ ❑9N558 KOSHARE TRL M Y N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 8 1II Ir_ COM VEH ❑ ® Ut - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST OF 3 T__.1 a_5 •(ryes,See Sidebar to H ELGIN IL 60124 0 3191927B IL 2025 REAR 0 fC/j, D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)200-9694 R362-4375-3369 IL D STFRM5F15BX031490 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 2872455-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m I I ' - #OCCS y / /• U1 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 1 ® 11 4 10;02 /2024 08 42 ❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP 0 AM Ut 2 ai 2 ❑ 2 99 ! / PM ❑Construction * N 3 El 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q CO 11 4 ARREST NAME / / ❑PM 0 Utility SLMT p U ❑CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ',3N AM 30 8 2 0 ARREST NAME r I pM ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El Y 30 414-Lara. Raul 401 404-Duffy ( / 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. 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 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z i- 1 ; i ; i- r r , , i INDICATE NORTH combination).or —I 3:1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! ' ' 1 ', ' ! ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----i-----• I I • : ' ' 1 1 1 i } - t transporting employees in the course of their employment(example employee 7.1 transporter-usually a van type vehicle or passenger car).or w r i 4 Is used or designated to transport between 9 and 15 passengers,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) 71 M Ja CARRIER NAME 2 ' .. ADDRESS 0 N o CITY/STATE/ZIP g . ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate < ❑ Not in Comm./Govt. El Not in Comm./Other O r---- ----, r r r r , l r • USDOT NO ILCC NO. m ,• • • Source of above z . IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 ' TRAILER VIN 1 m cn LOCAL USE ONLY TRAILER VIN 2 m (7 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. y 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE