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HomeMy WebLinkAbout2024-00064073 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III OII III 101111 IM I1OHIHO Mil IM HI 111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O35;93 8 u, 1 U2 1 1 1 1 U1 4 U2 1 U, 1 U2 1 Ut 1 Uz 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$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 • $ 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00064073 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 RT20 WB ® ❑ Elgin RELATED ❑Y coN 10 07 2024 06:05 ❑AM ❑YES ®NO U1 PRIVATE mo /day I yr ®PM FLOW CONDITION m 1 D(]�/MI N E S W Dwight St 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ®SLOW 1 U) Ell ICJ O g 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N [] FREE FLOW # LNS ' 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FRONT TOWED Ut 0 NAME(LAST,FIRST,M) 0 6 / day /1 9 8 7 Honda CRV 2012 00-NONE 11 O1 , DUE TO CRASH ❑ 21 13-UNDERCARRIAGE 191 I 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 2 m 1320 CARR ST F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF & I� 6 1 4 COM VEH ❑ ® 1 O a J H LRM3H56CC012365 Direct Auto ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same PAIL001031507 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) QUINONES. NANCY mo 0 5 Oa 1 yr 9 9 0 Mazda Mazdaspeed 6 2015 00-NONE +c)•• 12 s REETocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 9 3 X a` 1447 ASHWOOD DR F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j ! 4 COM VEH ❑ ® U1 to I— FIRST CONTACT 6 7__• ;_5 •Ifyes,See Sidebar ELGIN IL 60123 0 E576981 IL 2025 REAP 0 CC/>, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)660-9290 Q552-6209-0727 IL D JM1GJ1V55F1218265 Allstate ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 932132624 Bnc ' 3 • HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ❑Y N Same U1 _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m /• - #OCCS D / / U1 1 73 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 10,07 /2024 06 05 ®pM in a Work Zone? ®N DIRP co 1 I 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 ❑ 28 03 ! / 0 PM ❑Construction * c' 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q ® 11 1 ARREST NAME Esch.Carolina 11-601-Ax 153400007 / / ❑PM SLMT o U CI CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility 'd N 8 AM 55 2 0 ARREST NAME / / ppt ❑Unknown work zone type Ut T 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 55 1534-Santiago.Jorge 401 334-Fries 11 , 19/2024 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. r 0IF 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or —I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 1 1 i } - i• transporting employees in the course of their employment(example.employee M 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 • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , Source of above Z . 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 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 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 Silver RedEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE