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HomeMy WebLinkAbout2024-00060432 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi IIIIIII II 1111111111111111 101 1010111 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT 'COLL 'MANY X003579922' u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 3 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00060432 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I N MCLEAN BLVD Elgin ❑ RELATED ❑Y CON 09 20 2024 06:53 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl) 231 ®I MI N E OS W wing St WITH VEHICLES INVLD ElSTOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) FOR DAMAGED AREA(S) FRONT TOWED Ut 0 mo day yr 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 El U2 5 m 311 N CHICAGO AVE M ❑Y El NSYSTEM DUNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN I T. CITY PLATE NO. STATE YEAR POINT OF 8 i. 4 COM VEH 0 ® 1 0 F FIRST CONTACT 12 7_ 1—'-T.:_-.5 ^Yves,See Sidebar U1 Z JT2AE09V2R0072912 Kemper Ins Co ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 12AU001574935 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUM ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FROM TOWED Y N n NAME(LAST,FIRST,M) Roman.Jefte.J. 1 0 O mo a 1 9 9 3 Chevrolet Astro Van 2000 oo-NONE 1tr 1$ 0 ® 2 -I a yr 13-UNDER CARRIAGE 10 j - s FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a` 1248 RIDGEWAY DR M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF NTACT 6 O7 {a/; OS C•l OM gee SidebaH r IN U1 CO ELGIN IL 60123 0 EP26125 IL 2025 0E40 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)766-8140 R550-4309-3281 IL D 1GBDM19W3YB181358 American Heartland Ins Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same AHW1237751 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RElE Y NR Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMSi (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 El AM Did crash occur El U2 Z N ® 11 1 09/20 /2024 06 53 ®pm in a Work Zone? El DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 1 C) T 2 0 28 99 ❑AM ! / El PM El Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q ARREST NAME Lopez Cerezo. Manuel.A. 11-601 481000208 / / ❑PM SLMT ® 11 1 ❑Utilityp U ❑ ' CITATIONS ISSUED 0PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 481-Rodriguez. Hannah 602 - 10 / 15/2024 01 30 0 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 property and. Tx 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I combination) or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ • 1 1 ! 1 1 t I t -! r r r (example.shuttle or charter bus)-or T� n M.rma.r. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_-----.-----• + + L -r } } } transporting employees inthe course of their employment(exa mple employee transporter-usually a van type vehicle or passenger car or 03 �____A____: : i — — — — — _. i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O • L____-:_____; ; i } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11 • placarding(example placards will be displayed on the vehicle) m .Z1 *� u�t2 / CARRIER NAME Z IV_ I il � t ADDRESS '� Meirm, ' 1 I 1 I CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate wail O 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. C • , 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 M 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 ❑ No - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Red Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE