HomeMy WebLinkAbout2024-00063636 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III
010
�1 1III1011 IHO
HO III HIIII II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;938!
u1 1 U2 1 1 1 U199 U2 U1 1 U2 UI 1 U2 5 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
El NOT ON S
VEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) 123B Injury and/or Tow Due To Crash YR 2024I2024-00063636 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'I'I
S WORTH AVE ®gin DRELATED ❑Y coN 10 05 2024 07:14 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW U)
❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN El ® N PEDALCYCUST®N ❑ FREE FLOW # LNS 0
tg DRIVER 0 PARKED 0 ORNERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FRONT TOWED Ut 0
0 7 / 1 5 J 1 9 6 3 Chevrolet Cruze 2011 00-NONEDIJE TO CRASH
NAME(LAST,FIRST,M) , L. mo day yr 0 Q 0 El
13-UNDERCARRIAGE 10i z FIRE ❑ 1l <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 m
435 AIRPORT RD 123 M SYM
DY INN DUNK VEH. O AT CRASHD 0 99-UUNKNO4VN 9 16-TOP 3 'Distraction Value 9 ALGN 2
r CITY PLATE NO. STATE YEAR POINT OF 6 j 4 COM VEH 0 El 0
jL FIRST CONTACT 12 7 .i 6 .5_ 'Yves,See Sidebar U1
Z
1 G 1 PF5S94B7119727 NIA ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Clemens,Carrie,A. NIA 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
Fr RESPONDER y°DEN 495 AIRPORT RD 600. ELGIN , IL.60123 (630)803-7586 VEHU
5' ❑DRIVER ❑ PARKED 0 ORNERLESS ❑ PEE ❑PEDAL ❑EDUCE 0 WV ❑ CIRCLE NUMBER(S) U1
Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR 2 m
a / / FOR DAMAGED AREA(S) FRONT TOWED Y N
fi i DUE TO CRASH 0 0 —1
NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 73
C
c 13-UNDER CARRIAGE 10 I I 2 FIRE ❑ 0 U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPOR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 'Distraction Value UI 0 -
POINT OF
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT �_II a I_5 CIOMes 3eeSideba0 ❑ C
to
H �� • C
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 <
OPOQNR Ut I
(UNITE (SEAT) ;DOB) (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)r)TELEPHONE) (EMS) (HOSPITAL) C)
1 6 11 /27/1968 F 2 3 0 1 Carrie A. Clemens/495 AIRPORT RD 600,ELGIN-IL-60123 I—
(630)803-7586- U2 m
/ / #OCCS y
/ / U1 2 m
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z
1 N 1 I:� 43 1 Hermes.Saenz Garage door 10,05 ,2024 07 14 ®pm in a Work Zone? ®N DIRP co
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 El 135 S WORTH AVE ELGIN IL 60123 19 99
! / 0 PM ❑Construction *
c'J 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2
a ARREST NAME / / IDPM SLMT
o U 1 ID 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N AMpl ❑ Ut
30
8
2 El ARREST NAME r / pUnknown work zone type
T •
OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME
2 3 El ❑AM Workers present? ❑
1532-Hernandez, Daniel 601 - r / 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
; _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 truckrtrailer -<
r I I ; i combination).or
INDICATE NORTH Xi
135+1S+woeTI.MM. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', i -` ` r r r (example.shuttle cor rcharter rbus)-or
r C)
i_-----;-----% t } t porong employeeslin the cou se of theiremployrs and ment(example�emaployeect rier Om
lj
3 Is
} trans
transporter-usually a van type vehicle or passenger car) or w
i_____A____4 : i J °1flR'°T i 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
L____ ____; ; ; , i 1 5 Is any vehicle used to transport an hazardous material(HAZMAT)that requires
Y
placarding(example placards will be displayed on the vehicle) XI
ra
CARRIER NAME 1 1- Z
ADDRESS 'O
0 o
CITY/STATE/ZIP
r , Not To Scale - MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
USDOT NO. ILCC NO.
, Source of above Z
. 7)
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 ❑ 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
0
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 't Z
BlackEn
-
U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO
Redmons 1 Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO.
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE