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HomeMy WebLinkAbout2024-00064304 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Ell II 010 III 10 1010111 III 10 11 OH nn DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003579368. u1 9 U21 1 1 1 U1 2 u2 1 U199 U2 1 U1 99 U2 1 1 11 Ut 1 U211 *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[21 NOT ON 3 VEHICLE/PROPERTY ®OVER$1.500 ❑AMENDED ® B (DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00064304 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 RT20 EB ® ❑ Elgin RELATED ❑Y coN 10 08 2024 05:10 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day I yr ®PM FLOW CONDITION m ®1 043/MI N E S® South State ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED O PEDAL ❑EOUES 0 NNV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 . Unknown.0. Unknown Unknown 00-NONE 11 12 i' , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE �0 i 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 4 m UNKNOWN UNKNOWN SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 I PLATE NO. STATE YEAR POINT OF l COM VEH 0 ® 1 () F FIRST CONTACT 99 7 : �_6 Ifves,See Sidebar u1 0 Z UNKNOWN Unknown ❑Y ❑N U2 m 17EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L • ❑Y ®N 99 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Romero. Moira-S. lmo lday 1 9$4 Jeep(after 19S8�ngler 2008 oo-NONE ;o 112 s REEDcRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a 13N443 BURLINGTON RD F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distract Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j all, 4 ion COM VEH 0 ® U1to 1— FIRST CONTACT 6 7__ 5 •If Yes.See Sidebar Hampshire IL 60140 B EL72753 IL 2024 l 0 (Cjj, TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)623-4238 R560-5578-4958 IL D 0 1J4GA59178L608994 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Romero.Jose. M. 1823420SFP13 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 13N044 BURLINGTON RD. Hampshire. IL•60140 (224)522-8243 U1 = (UNIT' (SEAT) (DOB( (SEX) ISAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAMEI/t ADDRESS i(i TELEPHONE I (EMS) (HOSPITAL) 2 6 08 /1 9/2011 F 2 4 0 1 Samantha Romero/13N443 BURLINGTON RD.Hampshire,IL,60140 996 1— (224)363-7175 , U2 m 2 4 10 /09/2014 F 2 4 0 1 Daniela Romero/13N443 BURLINGTON RD-Hampshire-IL-60140 #OCCS D (224)762-2100 _ X / / Ut 1 m / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ®Y U2 Z N i ® 11 1 10/08 /2024 05 30 0 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 3 C) T 2 0 03 28 ! / 0 PM ®Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 3 1 CO 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N 8 AM 45 1 2 0 ARREST NAME r I ptil El Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 537-Sanders, Richard 701 334-Fries / / ❑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 1 - 1 combination) or 'I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C .,, ', i © _No i7b_Sceb,; -i i r r r (example'.shuttle or charter bus)-or 0 ---- ----% I t } i transporting 15 or fewer the course their employment(example�emaployeerier 07 3. I s } transporter -usually a van nvehicle or car). i__ _ A____: : , —— — i C a for direct compensation(example:large van used for specific purpose).or L____-L____; i , , MUMSliff 0 * �r•� _ i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m •o placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' I t ADDRESS 0 N • '• CITY/STATE/ZIP 0 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 If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? O ❑ Yes No ❑ Unknown 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 7a 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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