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HomeMy WebLinkAbout2024-00063927 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii 1110111111 III 1001 ID II HO M Ill IM HI DII nn DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O35;93 1 u, 1 U2 1 3 4 1 U1 1 U2 1 U, 1 U2 1 Ut 1 Uz 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 2 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063927 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'F'I S MCLEAN BLVD ®gin El ❑Y coN 10 07 2024 06'49 ®AM El ®No u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m IP0 /MI N E S W College ) Kane HIT&RUN ❑V ® N PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 / 2 3 /2 O 0 3 FOR DAMAGEDAREA(S) FRONT TOWED U1 ,Saul NAME(LAST,FIRST,M) mo day yr Honda Accord 2025 -NONE 11 1$ 21 1 DUE TO CRASH ❑ 13-UNDER CARRIAGE lo r 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 2 m 752 HIGH ST M SY 15-OTHER ❑Y ®SNE❑UNK VEH. n AT CRASH M IN ENGAGEDO 99-UNKNOWN 9 16-TOP 3 'Distraction Value ALGN 2 CITY PLATE NO. STATE YEAR POINT OF & 1� 6 1 4 COM VEH 0 ® 1 0 A ~ 1 HGCP36848A077758 Aamerican Freedom ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 9 Miranda-Garcia,Cipriano 12-2394071-01 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > o RESPONDER y°®EN 752 HIGH ST. ELGIN , IL,60123 (224)400-2874 VEHU G1 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m 1 / / FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) Reyes,Ana-G. lmo 1 day 1 9$8 Toyota Camry 2018 oo-NONE +c I 1$I. s REoCRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n a` 1695 MAPLE LN 2 F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 3 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 1 COM VEH ❑ ® UI to I— FIRST CONTACT 6 Q 0•byes,See SidebarC ELGIN IL 60123 0 BG20244 IL 2025 i C.n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)622-7018 R200-0078-8922 IL D 0 'JTNB11 HK8J3021627 Progressive ❑y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 946001421 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y El NR Same Ut = (UNIT( (SEAT) (DOB) )SEX) (SAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (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 ®AM Did crash occur ❑Y U2 Z N ® 11 1 10/8/ /024 06 49 ❑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 5 C) T 2 ❑ 03 15 ! J 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 5 Q CO 11 1• ARREST NAME Sandoval.Saul 11-601-Ax SO471-000121 / / ❑PM SLMT o U ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility N AM 30 2 ❑ ARREST NAME Sandoval.Saul 6-101-A SO471-000122 r / 8 ptit El Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 471-Evans, Lakysha 702 - 11 r 2/ /024 09 00 ❑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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I . 0" ADDITIONAL UNITS FORMS ' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' r • ; i ; i- r r , , i INDICATE NORTH combination).or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ I ', ! i. ._ ' ' '. ', ' I ` r r r (example'.shuttle or charter bus)-or n S ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N . O • CITY/STATE/ZIP 0 , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, i r '- DO ILCC NO. m U N XI , Source of above Z ❑ 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to 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 Gold White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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