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HomeMy WebLinkAbout2024-00066391 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III III ll II 11111111111111111011111100110 IIIIIU212 1 1 U199 U299II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E450 u, U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENEEl NOT ON 1 VEHICLE/PROPERTY ®OVER$1.500 El AMENDED ES) (DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00066391 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 1T GRACE ST ❑Elgin RELATED ❑Y coN 10 17 2024 02:00 ❑AM ❑YES ®NO U1 ,-< PRIVATE mo /day/yr ®PM FLOW CONDITION m 1 0 /MI N E S Dwight St COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U1 ®�'-1 ® ® g WITH VEHICLES INVLD El STOPPED U2 —1IJ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 0 FOR DAMAGEDAREA(S) FRO TOWED U1 2018 H undai Santa Fe 00-NONE 1 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) Leon,Jair.A. mo / day J M yr Y ®I 12 3 13-UNDER CARRIAGE 101 I 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ElI� U2 02 m 1777 MATTHEW LN M ❑Y ESYlM DUNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = W. CITY PLATE NO. STATE YEAR POINT OF 6 !1 6 II._4 COM VEH 0 El 1 0 ~ KM8SNDHF1JU283380 Progressive ❑Y IX N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Bathje, Nicole,J. 954274507 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > RESPONDER 1777 MATTH EW LN ,Aurora, I L,60504 VEHU GI L ❑Y ®N 2 17 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FROM TOWED Y N s Perez Gil, Uriel 0 3 1 21 9 7 5 Nissan Altima 2015 00-NONE O' �'D1 DUE TO CRASH ❑ ® 2 XI NAME(LAST,FIRST,M) mo day yr Q, ✓ t3-UNDERCARRIAGE 10, fj 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPOR C) E 668 THORN DALE DR M SYSTEM IN 0 ENGAGED Q 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO P RI8T COONTACT F 12 7_1 a �' _5 •CIOMe6VSee Sidebar ® U1 H ELGIN IL 60120 0 Z887621 IL 2025 MAR 0 al CC/1 D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)740-2431 P624-8407-5074 IL Other 0 1 N4AL3AP3FN86529 StateFarm ❑Y ®N RDEF EMS AGENCY PEDV PPA + PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Lopez,Guadalupe 0373168-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°®NR 1 668 THORNDALE DR, ELGIN , IL,60120 U1 = (UNIT' (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONEI (EMS) (HOSPITAL) n 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 El AM Did crash occur ❑Y U2 Z N ® 11 1 10/17 /2024 02 11 ®PM in a Work Zone? ®N DIRP D 1 r 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 ❑ 18 99 ! / 0 PM El Construction * N T 3 0 izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Salgado Leon,Jair,A. 6-303-A S1537-000011 / / El PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8 AM 30 2 ❑ ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1537-Mapp,Teddron 401 - 11 104/2024 09 00 p 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 Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer or r ; ', IYO!To Scale I ! NDICATE NORTH combination) XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', ', ' -t ` r r r (example.shuttle or charter bus)-or n i .....,... L a Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.----.....---% -i } - i transporting employees in the course of their employment(example employee 7.1 transporter-usually a van type vehicle or passenger car).or CO i_____A____: : i , GracePBt : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N .nit 2 der for direct compensation(example:large van used for specific purpose).or O L----'- --- -; , , t y ) 15 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 1 CARRIER NAME Z ' t ADDRESS 0 N . F CITY/STATE/ZIP O N-D MOTOR CARR ID ❑ Interstate ❑ Intrastate r , 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. XI , Source of above Z . If Yes, Name on placard O 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 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 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 Blue-Dark Maroon - 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