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HomeMy WebLinkAbout2024-00062950 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III II 0 lu II 11111111111 IIIIHIIIIIIIIIIIIOIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035;T;344 u, 1 U2 1 2 4 1 U116 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE • 1 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00062950 VENT * ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 SPARTAN DR ® ❑ Elgin RELATED ®Y ❑N 10 02 2024 11:52 ®AM ❑YES ®NO U1 .•< PRIVATE mo /day I yr El PM FLOW CONDITION m FT/MI N E S W S RAN DALL ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) . PEERUNPORN 1no 0 / 3day yr 0 J1 98 8 Honda CRV 2019 00-NONE 11 Ol' , DUETOCRASH ❑ 13-UNDER CARRIAGE 10 DI I I 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 99 m 2808 WATERFRONT AVE F ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF & I� e l 4 COM VEH ❑ ® 1 O 5J6RW2H54KL035847 PROGRESSIVE ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same 981890922 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑N 2 G0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m 4 / J FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) BELLINASO. KARI,J_ 0 mo day 1 9 5 3 Hyundai Santa Fe 2019 00-NONE +c1 12 s DUREETOCRASH ❑❑ ® U2 2 C I', yr 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 O X a` 5330 W ARDMORE AVE F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j ! 4 COM VEH ❑ ® Ut to FIRST CONTACT 6 7__• ;_5 •If Yes,See Sidebar 2 CHICAGO IL 60646 0 FIG10 IL 2025 fort 0 CC/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (312)316-2267 B452-5105-3718 IL D 0 5NMS5CAA8KH058766 STATE FARM ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 01 48735SFP1 3 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same Ut = (UNIT) (SEAT) (DOBi ISEXI (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS( (HOSPITAL) I I U2 996 1- m /• - #OCCS D / /• 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 1 ® 1 1 4 10,2/ /024 11 52 ❑pti, 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 8 C) T 2 ❑ 28 99 ! I 0 PM ElConstruction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 8 ❑AM ❑Maintenance uz Q 1 CO 11 4 ARREST NAME VINIJPITTAYAGUL. PEERUNPORN 11-601 w244-1780 / / ❑PM SLMT o u CICITATIONS ISSUED ElPENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N 8 AM 30 2 0 ARREST NAME ( / ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 244-Blomberg. Michael 702 272-Bajak ( , ❑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. ^ 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 proty and. Z r-"--r---'4 4 4 r r r r r 1 I . r 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtra periler -< r i ; i r r i i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i I ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or n S ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - 1 1 1 i } - t transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or 03 ' 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 T. . ` CARRIER NAME 2 ' ADDRESS 0 N • CITY/STATE/ZIP 0 ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 G r-----.-----, r r r r r----, i r USDOT NO ILCC NO. m • , Source of above z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No P3 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 E D Did Carrier Safety Regulations(MCS)violation contribute to the crash% p ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? r. HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m LOCAL USE ONLY TRAILER VIN 2 m 0 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 Black Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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