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HomeMy WebLinkAbout2024-00063654 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II II I Ill OII III 1III1011 lIOfl 010�110III IM 110 111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003579370' u, 1 U21 1 1 1 U144 U2 1 U, 1 U2 1 U1 1 U2 1 5 9 U1 1 u221 *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 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00063654 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'TI E CHICAGO ST ❑ U1 Elgin RELATED ❑Y coN 10 05 2024 08:45 ❑AM ❑YES ®No .< PRIVATE mo /day I yr ®PM FLOW CONDITION m D COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) 235 ®/MI ON E S W Porter St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER 0 PARKED 0 ERNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n 0 6 / 0 7 /1 9 9 9 FOR DAMAGED AREA(S) FRONT TOWED U1 . Emmanuel Mitsubishi Lancer 2006 00-NONE Q..O..D1 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE ❑10 2 ICI SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 679 MORGAN ST M SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASH D 0 99-15-UNKNOWN 9 16-TOP 3 Distraction Value 3 ALGN I THER j • COMVEH 0 r CITY PLATE NO. STATE YEAR POINT OF 8 i FIRST CONTACT 12 7_.; 4:_.5 • El3 O m F 6- Y Yes,See Sidebar U1 Z JA3AH86C16U011618 Statefarm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 TREY JACKSON MOTORS 3388010SFP13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPOND E ER N 1587 LEE ST. NEW BRAU N FELS.TX.78130 (830)625-8739 VEHU G1 0 DRIVER ® PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGEDAREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Ford Focus 2014 00-NONE 11_ 12 y DUE TO CRASH ❑ 1 73 c 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value g 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 ( 4 COM VEH ❑ ® U1to F FIRST CONTACT 6 Q •It Yes,See Sidebar CZ73529 IL -REAR 0 cn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 Kemper 0 Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 9 TREY JACKSON MOTORS 12RA000004899 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 995 < 0 YONDE NR 1587 LEE ST, NEW BRAU N FELS.TX.78130 (830)625-8739 U1 = (UNITE (SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) C) I I U2 996 r m / / - '#OCCS > / /• U1 1 m 11* / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 1 10,05 ,2024 08 45 ®pm in a Work Zone? ®N DIRP co 1 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 ❑ 08 43 ! / 0 PM ❑Construction * t N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM ❑Maintenance U2 7 ARREST NAME Herrera. Emmanuel 11-708 75233 / / El PM SLMT c U , ® 11 1 ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility N AM 30 2 0 ARREST NAME Herrera. Emmanuel 11-501-A-1 75232 r /1,1 8 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 1509-Wortman.Cassie 301 334-Fries r / ❑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 I i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , L i_ I + Not To Scale I 0 I. (example.shuttle or charter bus)-or 0 r r r 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----......-.... 4 i -i } - i transporting employees in the course of their employment(example.employee M N.W r7St. transporter-usually a van type vehicle or passenger car).or w i.____A____: : i , E•11ChL0 go7SL : i 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____-:_____4 4 ; , Unll 2 Unll 1 i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI b — ` I. CARRIER NAME Z ' ADDRESS 0fD/1 CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above Z . Were HAZMAT placards on vehicle'? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 73 m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr 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 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO © DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Redmons I Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE