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HomeMy WebLinkAbout2024-00063628 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 1111111 DIII III )III IIIIIII II 11111111111111011111 IIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;38r ut 2 uz 1 1 1 1 Ut 16 u2 1 u, 1 u2 1 u, 1 U2 1 3 13 Ut 16 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$507-$1.500 ®ON SCENE 14 0 NOT ON S VEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00063628 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT WALNUT AVE ® ❑ Elgin RELATED ®Y ❑N 10 05 2024 06:16 DAM ❑YES ®No Ut .•< PRIVATE mo /day I yr ®PM FLOW CONDITION m qD ® ® 'COUNTY PROPERTY El Y M N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) II-XX'-1l13_ /MI N E 5 Wilcox Ave 'WITH VEHICLES INVLD El STOPPED U2 -I IJ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y El 11. PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NW ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FRONT TOWED Ut y O L. 0 7 / 1 5 J 1 9 6 3 Chevrolet Cruze 2011 00-NONE 11 1s i' , DUE TO CRASH El ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL (�-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 435 AIRPORT RD 123 M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN O9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF ®(I ji 4 COM VEH 0 ® 1 (7 r' ~ 1 G1 PF5S94B7119727 NONE ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Clemens,Carrie,A. NONE 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L RESPONDERN 495 AIRPORT RD 600, ELGIN • IL,60123 (630)803-7586 VEHU 73 5 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m / J m FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) Anselmo,Jasmine 0 6 0 6 2 D 0 3 mo day yr Toyota Corolla 2005 00-NONE O' 1' + DUE TO CRASH 0 ® 2xi v 13-UNDER CARRIAGE ) ©I I 2 FIRE El ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 IN SPUR 0 a` 65 PARK ROW F SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 9 9 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •OistractionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ©) 4 COM VEH ❑ ® U1 to I— FIRST CONTACT 11 Q� 6 5 •If Yes,See Sidebar ELGIN IL 60120 0 DR54638 IL 2025 I 0 ((I M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)258-3100 A524-4200-3774 IL D 2T1 BR32E45C462163 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 961614605 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < RESPONDER NR Same U1 = (UNITE (SEAT) IDOBi )SEX) (SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME!/(ADDRESS)/ITELEPHONE) (EMSt (HOSPITAL) 1 3 11 /27/1968 F 9 3 B 1 Carrie A. Clemens/495 AIRPORT RD 600,ELGIN-IL-60123 Elgin Fire Provena St.Joseph U2 996 1 (630)803-7586 m 2 6 09 /29/2021 12 3 0 1 Alexis S. Hernandez/300 SENECA ST 4.ELGIN-IL-60120 #OCCS D (224)363-9148 _ X 2 3 09 /24/1990 M 2 3 0 1 Luis Y. Hernandez/976 S LIBERTY ST B.ELGIN•IL•60120 Ut 2 m (224)508-7966 , D W 06 /05/1963 F Antoinette Medina/502 TYLER DR .-•60110/ (224)209-3050 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY 1 POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z 1 N 1 ® 11 3 in a Work Zone? ®N DIRP co City of Elgin Fire Hydrant 10/05 ,2024 06 16 ®pm r PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 C) -- T 2 0 150 DEXTER CT ELGIN IL 60120 19 20 / / ❑PM 0 Construction F N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q ARREST NAME Tison,Troy, L. 3-707 752308 / / ❑PM c U 1 ® 1 1 1 CITATIONS ISSUED PENDING • TIME 0 Utility SLMT o N ® ❑ SECTION CITATION NO. ROAD CLEARANCE AM 30 2 0 ARREST NAME Tison.Troy, L. 11-709-A 752304 / / 8 ptil ❑Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? El 30 487-Heal, Kayla 701 - 11 ;01 /2024 09 00 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 weight rating more than 10,000 pounds(example truck or truck/trailer r 'I 1 - 1 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 d i ( - -t ` r r r (example.shuttle or charter bus)-or r w X mnw. r ,,,,, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------:-----% -i } - i transporting employees in the course of their employment(example.employee M 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 J —__- for direct compensation(example:large van used for specific purpose).or O —Jett .wn.ma. L_ -____1 . - - - - - , i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires �� 1 • placarding(example placards will be displayed on the vehicle) n v �1 CARRIER NAME Z ronwes na e 0 ,,,,,,r,,,,,,,,,e i. , ADDRESS N O • Not To Scale CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above 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? O ❑ 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 Form Number 0 M 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 >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 Gold - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE