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HomeMy WebLinkAbout2024-00063532 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III III 0 lu II 111111111111110111111111010111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;324 u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 11 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 1 EI NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00063532 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 S MCLEAN BLVD ❑Elgin RELATED ❑Y coN 10 05 2024 08:47 ®AM El ®No u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m 20Q3 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) /MI N O E S W Lillian St 'WITH VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS O DA oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 C) FOR DAMAGED AREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) , Edwin,J. Ford Escape 2014 00-NONE mo 1 1 / day J yr 11 1z 1 -1 DUE TO CRASH ❑ 21 13-UNDERCARRIAGE 1D I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10U2 6 m 856 W HIGHLAND AVE M SYTM❑Y ®S NE❑UNK VEH. O AT CRASH D O 99-U 15-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 116 I. COM VEH 0 El 1 n il FIRST CONTACT 12 7 71_ 6 •If Yes,See Sidebar U1 0 Z 1 FMCU9G94EUD54304 First Chicago Insurance C ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same ILV103238900 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑N 2 G0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) Tucker,Julian, L. 0 9 day 1 9 9 6 Acura Integra 2024 00-NONE 'o) 12 Y REo CRASH ❑❑ ® Uz 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR n E 9151 WAYM O N D AVE M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i ^ 4 COM VEH ❑ 21 U1to I— FIRST CONTACT 6 7_ _S •ItYer,,See Sidebar C Highland IN 46322 B CDS443 IN 2024 REAR 0 (1 D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (219)629-6559 3630326507 IN D 19UDE4H2XRA006980 Farmers Insurance ❑Y ®N RDEF73 EMS AGENCY PE DV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 193308527 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same Ut = (UNIT' (SEAT) (DOBi ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EIdSI (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 ® 11 1 10,05 ,2024 08 47 ❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C) T 2 ❑ 03 15 ! / 0 PM ❑Construction >F N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ARREST NAME Forero Gonzalez, Edwin,J. 11-710-A W410000668 / / ❑PM SLMT CO11 1 ❑Utility p U 0CITATIONS ISSUED ❑ ' PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 A• 30 2 ❑ ARREST NAME / / pMpl ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 410-DeLeon,Jessica 602 404-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. F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A . . ADDITIONAL UNITS FORMS , I �I I I r r A CMV is defined as any motor vehxae used to transport passengers or property and. j0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer { combination) or XI r ', ', r INDICATE NORTHXI I �I I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I d i -` ` r r r (example.shuttle or charter bus)-or n 3 Is designed to carry 15 fewer passengers andoperated carrier III ----?-----� -r } } t transorting employees in the course of their employment(example�emaployee730 N transporter-usually a van type vehicle or passenger car) or w A ...l. .l. . I I I my . i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I ) for direct compensation(example:large van used for specific purpose).or 11 -; ; . . A wren t i iany 5 Is any vehicle used to transport hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) m71 T. CARRIER NAME Z ' — ADDRESS 0 N .• O ' ' I 1 I it Not To Scala I - CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate I I I I r 0 Not in Comm.lGovt. ❑ Not in Comm./Other Q USDOT NO. ILCC NO. m , Source of above Z • . 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 ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 rn 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 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 ft Z Black Silver - 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