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HomeMy WebLinkAbout2024-00063586 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III III 0 lu II II 11111111111111011111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35;T;365 u1 9 uz 1 1 1 1 UI 7 U2 1 U199 U2 1 U1 1 U2 1 1 12 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 0 NOT ON VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063586 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 N MCLEAN BLVD ❑Elgin RELATED ❑Y co" 10 05 2024 02:57 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W WOLFF AVE 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ID SLOW 1 U1 ❑ 'WITH VEHICLES INVLD El STOPPED U2 —1 El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0 DI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 ,O. Nissan Altima 2011 00-NONE ®i 12 , DUE TO CRASH p 21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( 2 FIRE 0 IA 4 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® U2 m SYEl Y El CI UNK VEH. O AT CRASH O 99-UUNKNOWN THER 9 �6-TOP 3 .Distraction Value .. g ALGN r CITY PLATE NO. STATE YEAR POINT OF 6• !1 6 it 4 COM VEH 0 El 1 0 F ID VIN INSURANCE CO. EXPIRED 1 16 1 N4AL2AP5BN494483 NIA ❑Y 0 N U2 m m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y r Lopez Hernandez,Jesus NIA 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L RESPONDERN 385 AN N ST.SOUTH E LG I N . IL.60177 (224)762-9106 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 99 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) Schaffer.Alfred 0 6 2Uey 1 yr 9 5 3 Hyundai Azera 2015 00-NONE 11, 12 s RE o CRASH ❑❑ ® Uz 2 XI v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR 0 a` 1830 W HIGHLAND AVE M SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 9 0 X ❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistrachon Value N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 1(O� Yee,See Sidebar COM VEH ❑ ® U1 al F, FIRST CONTACT 5 7__. e—.1 •If E LG I N I L 60123 0 6007775 IL 2015 REAR 0 O .n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)910-0899 S160-0005-3180 IL D KMHFH4JG1FA432231 Progressive ❑" ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 982487226 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y 0NR Same U1 = (UNIT( (SEAT) (DOB) (SEX) (SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m #OCCS y / / 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 1 10,05 /2024 02 57 ®pm in a Work Zone? El 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 1 C) T 2 ❑ 03 99 ! ( ❑PM ❑Construction * N 3 El 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 AM ❑Maintenance uz Q 1 ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 30 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1532-Hernandez, Daniel 601 246-Kite ( / 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. 0_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D ) 1 Has a weigh t rating more than 10,000 pounds(example truck or truck/trailer , r I I ; I Ll. l. INDICATE NORTH combination) or —I Xi WOLFF?AVE BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. ', d i -` ` r r r (example'.shuttle or charter bus)-or n X t.-----i_----% . + m -t } - i designed 5 or fewer passengers and d contract rer transporting employeesin the course thlempb operatedent(example employee 730 -usually a van vehicle or _____________: : , r� i r i 4 transporter Is usedordesgnatedto transportpassenger r between9ag15passengers,including the driver, for direct compensation(example:large van used for specific purpose).or L y 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M placarding(example placards will be displayed on the vehicle) 71 YAPLE7uv. J I N CARRIER NAME Not To Scale j ADDRESS 0 To • CITY/STATE/ZIP , I I l. MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z • . ❑ Yes 0 No ❑ Unknown A 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 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE