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HomeMy WebLinkAbout2024-00066048 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I III ll II 111111111111111111H1 11111 II 111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003590635 u, 9 uz 1 1 1 1 Ui 8 U2 1 U199 U2 1 U1 99 U2 1 1 12 U1 14 U2 1 *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 ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY ®OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066048 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 N STATE ST ❑Elgin RELATED ❑Y coN 10 16 2024 07:17 ®AM ❑YES ®NO U1 .•< PRIVATE mo /day I yr El PM FLOW CONDITION m FT/MI N E S W FRAZI E R ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS O DI DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NNv ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) .0. mo day yr Unknown Unknown 2019 00-NONE 11 12 y,/DUE TO CRASH ❑ 13-UNDERCARRIAGE � FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O SYSTEM IN ENGAGED t5-OTHERWN DISTRACTED ❑ I U2 2 m 9 16-TOP 3 M ❑Y ❑N ❑UNK VEH. AT CRASH POINT OFO 6 {I ii 4 COM VI EH ion�� 0 ® ALGN CITY PLATE NO. STATE YEAR { 6 1 w F unknown ❑Y ❑N U2 m m M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same unknown 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L • ❑Y ®N 99 0 s ® RIV DER El PARKED 0 DRNERLESS PED ❑PEDAL EQUES 0 WVElNCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) mom TOWED l 1 9 9 3 Mitsubishi Outlander 2022 oo-NONE ; 1Y , y NAME(LAST,FIRST,M) Castillo Pineda. Mayra.S. FIREDUE ❑TO ❑ ® U2 273 0 v mo day 13-UNDER CARRIAGE 0® I.-2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X a` 1617 COLLEGE GREEN DR F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN II •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 11 7_1 6 �_5 C•IOMeSVSee Sidebar ® U1 to H ELGIN IL 60123 0 AR46846 IL 2025 I 0 CCn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)232-9677 C234-5579-3933 IL D 0 JA4J4UA8ONZ010934 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 16958743FP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNIT) I SEAT) ;DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)/(TELEPHONE) EMS) (HOSPITAL) 1 6 03 /22/2020 F 12 4 0 1 Emma C. Medina/1617 COLLEGE GREEN AVE 1,ELGIN.IL.60123 - 996 r (224)232-9677_ U2 m / / #OCCS D / / • UI 2 m / 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 10/16 ,2024 07 17 ❑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: Ut 5 C) T 2 0 20 99 ! / 0 PM ElConstruction * N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 AM ❑Maintenance uz Q 1 ® 11 1 ARREST NAME / / El PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME "'p N IIAM 35 2 0 ARREST NAME r I PM ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? El Y 35 1544 Solis.Yulissa 501 272-Bajak i , p PM ElN 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 I F 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. ,� 1 Has a weightD rating more than 10,000 pounds(example truck or truck/trailer r } I I i I combination)or —I N NDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. ', -` r r r (example'.shuttle or charter bus)-or n X L____a-___. I lk. Fraaer?Ave -i : } i transporU^gemployeeed to slinthecours5 or fewer eaoftheiremployrs and ment(example�emaployeect rier .ZOI} tr -usually a van vehicle or passenger �____-:--_-_: : , — — — — I. i- 4a Is usedror designated to trransport between 9 and 15rpassengers,including the driver, u) ' for direct compensation(example:large van used for specific purpose).or O L____-:____-; 4 ; , N,pStste7St, 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 [10# I. -1 " CARRIER NAME Z ' ADDRESS 0 f(/1 I CITY/STATE/ZIP Not To Scale I MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other ' USDOT NO. ILCC NO. XI , Source of above Z • . GVVVR/GCWR ❑ <10,000 0 10,000-26,000 0 >26,000 Z Were HAZMAT placards on vehicle'? ❑ Yes ❑ No If Yes, Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 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 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 Black SilverEn - 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