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HomeMy WebLinkAbout2024-00063171 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III (III IIIIIII II 1111111111111101111HI 1110 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003574357 u1 9 uz 1 3 4 1 ut 99 u2 1 U199 U2 1 U199 U2 1 1 10 Ut 1 u2 3 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ❑ON SCENE • 3 jg NOT ON VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063171 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH gg -n N STATE ST ❑Elgin RELATED ®Y ❑N 10 02 2024 03:15 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W BIG TIMBER ) Kane HIT&RUN ®Y El I' PEDALCYCUST®N ❑ FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 . Unknown.0. Unknown Unknown 00-NONE 11 12 i' 1 DUE TO CRASH ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) .r 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 6 m UNKNOWN UNKNOWN SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 I PLATE NO. STATE YEAR POINT OF l COM VEH 0 El 1 () FIRST CONTACT 99 7_ : �_6 "If Yes,See Sidebar U1 0 Z UNKNOWN Unknown ❑Y ON U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y r Same Unknown 1 m I— o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 99 G-) 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / 0 / FOR DAMAGED AREA(S) FRO147 TOWED Y N NAME(LAST,FIRST,M) Solorio Serrano, Kristian,A. 0mo ld y 1 yr 9 8 5 Nissan Rogue 2008 Do-NONE +c 112 s FIREETocRasH ❑❑ ® U2 2 C v t3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPUR 0 E 750 ADAMS ST F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y E1 N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 j ! 4 COM VEH 0 ® U1 al F- FIRST CONTACT 6 7-.1-- -_11-5 •If Yee See Sidebar C ELGIN IL 60123 0 EK91647 IL 0 C/>, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)417-1425 S462-5018-5734 IL D JN8AS58V18W100651 First Chicago ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same I LS989298-00 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER Same U1 = (UNIT' i SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)(!ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) - 2 6 1 2 /1 5/2023 F 13 3 0 1 Axel E. Argumedo Aguilar/750 ADAMS ST,ELGIN,IL,60123 996 U2 m m 2 3 02 /23/2006 F 2 4 0 1 Krystal Silva/750 ADAMS ST,ELGIN,IL,60123 #OCCS D (224)460-4621 _ 2 5 09 /28/2005 F 2 3 0 1 Jennifer Aguilar/750 ADAMS ST,ELGIN,IL,60123 lit1 m (33112 22-1 5 9 0 , D / / 4 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N i ® 11 1 10/03 /2024 02 45 ®pm in a Work Zone? El DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T 2 ❑ 18 18 ! / 0 PM 0 Construction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME "'p NIIAM 35 2 ❑ ARREST NAME I I pti1 ❑Unknown work zone type Ut 1,1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 35 537-Sanders, Richard 501 334-Fries I I ❑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 4 _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I 4 combination) or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I +, d i -` ` r r r (example.shuttle or charter bus)-or n S 3 Is designed to carry 15 fewer passengers andoperated r -----t-----+ + -! transorting employees in the course of their employment(example�emaployeerie ,3 -- — Not TO SOW , transporter-usually a van type vehicle or passenger car).or w i_____A____: : , _ _ _ : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O , I~I t I t y 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) J—a I T. CARRIER NAME z ' I n ADDRESS 0I N • • CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. ,• Source of above Z . If Yes, Name on placard O 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? ID 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to 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. Z Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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