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HomeMy WebLinkAbout2024-00064781 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111010 III (III IIIIIII II 11111111111111111111111101111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003582615 u, 1 U21 2 4 1 U1 2 U2 1 U111 u2 1 Ut 1 U2 1 1 15 Ut 1 u2 1 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S Ed$501-$1.5000 NOT ON S®ON SCENE 1 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) l$l B Injury and JorTow Due To Crash YR 2024I2024-00064781 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 WATERMARK TER ® ❑ Elgin RELATED ®Y ❑" 10 10 2024 04.32 ❑AM ® 1 1 ❑YES NO U1 .•< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FitO4T TOWED Ut O NAME(LAST,FIRST,M) 1m0 / a J 1 9 4 4 ay yr Tesla Model 3 2023 Do-NONE 13-UNDER CARRIAGE 11 .i O..0DUE TO CRASH El - E ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O FIRE DISTRACTED 0 53 U2 2 m 12801 GOLF VIEW DR M ❑Y ®SNE❑UNK VEH. 0 SYTM ATCRASH 99-UUNKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = THER r CITY PLATE NO. STATE YEAR POINT OF 9 i. 6 4 COM VEH 0 ® 1 n FIRST CONTACT 1 7_ ? • 5 •Yves,See Sidebar 1.11 Q Z 5YJ3E1EB9PF636474 N/A ❑Y ❑N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same N/A 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU 73 ❑Y ❑" 2 G) 5 ®DRIVER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDALL ❑EOUES ❑NUV ❑NCv ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Babicz. David 0 0 DaY 1 9$9 Mack Trucks. I U613 2013 00-NONE 11: 12 '_s DUE TO CRASH 0❑ ® U2 21 C v 13-UNDER CARRIAGE I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ®376 DENBERRY DR M N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 1, 4 COM VEH El U1to H FIRST CONTACT 00 71. 5 •If Yes,See Sidebar C Lake Zurich IL 60047 0 2114653 IN 2025 0 fn n TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (312)451-4738 B120-1608-9001 IL A 7 1 M1AW09Y2DM035228 Liberty Mutual ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I United Parcel Service AS2-C21-004175-334 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 POEl N 2100 HICKS RD. Palatine. IL.60074 Ut = (UNITE I SEAT) (DOBi (SEX) )SAFT) (AIR) (INJ( (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'/(ADDRESS]l(TELEPHONEI (EMSI (HOSPITAL) 1 3 07 /30/1936 F 2 3 B 1 Charlotte Tuggle/12801 GOLF VIEW DR.Huntley.IL.60142 Elgin Fire Sherman 996 (773)414 5468 _ g U2 m / / #OCCS D XI / / u1 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 10/10 ,2024 04 32 ®pM in a Work Zone? ®N DIRP D 1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 5 ., 2 0 23 99 10,10 /2024 04 33 ®PM El Construction * N T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 ® 11 4 ARREST NAME Silva.John 11-1204-8 1532-000288 10/10/2024 04 39 ®PM SLMT o U ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 'd AM30 1 2 0 ARREST NAME Silva.John 3-707 1532-000286 10/1 0 /2024 05 15 ®PM 0 Unknown work zone type U1 2 2 3 0 • • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 1532-Hernandez. Daniel 901 - 11 , 12/2024 01 30 0 PM IZI 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. _ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r_.._r_ __1 1 , A CMV is defined as any motor vehicle used to transport passengers or property and. 0D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r ' 1 - i -; ; combination) or 'I INDICATE NORTH 7:1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 i -! ` r r r (example.shuttle or charter bus)-or n X L----------% i -i t } t transporting employeeslin the course their employment(example�emaployeerier O,3. I s } i-____-----_: : , YO01Y2'"'" ' L i r i 4 transporter sedor des gnated to rra-usually a van nsport between 9 avehicle or gar 15carpassengers.including the driver, C for direct compensation(example.large van used for specific purpose).or O L____-�___-1 . y 1. 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 11 2 placarding(example placards will be displayed on the vehicle) m Z1 1 [41r • • • CARRIER NAME United Parcel Service Inc. Z N ADDRESS 55 G LE N LAKE PKWY D Arai*Scat. 1 cn CITY/STATE/ZIP ATLANTA 1 GA/30328 r , MOTOR CARR ID ❑ Interstate E Intrastate Not in Comm./Govt. 0 Not in Comm./Other r , USDOT NO. 21800 ILCC NO. , Source of above Z . 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 E No 2 Z Form Number 0 m XI IDOT PERMIT NO 21800 WIDELOAD% ❑Yes E No = TRAILER VIN 1 3H3V532K4RJ293195 m N LOCAL USE ONLY TRAILER VIN 2 m 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 53 ft 2 ft. Z Blue Bronze u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES 2 DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 0 TOWED BY/TO. DUE TO © VEHICLE CONFIG 6 CARGO BODY TYPE 2 LOAD TYPE 5