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HomeMy WebLinkAbout2024-00066651 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II 1111111111111111101110111111III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035°3592' u, 1 U2 1 2 4 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 15 U1 11 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 14 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066651 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 11 ST CHARLES ST ® ❑ Elgin RELATED ®Y ❑N 10 18 2024 0,428 ❑AM ❑YES ®NO U1 ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W BENT ST 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR 0 SLOW 1 U) ❑ 'WITH VEHICLES INVLD 0 STOPPED U2 —1 El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 / 0 1 J 2 0 0 4 FOR DAMAGED AREA(S) FRONT_ TOWED U1 Infiniti G35 2012 oo-NONE 11 O1 , DUE TO CRASH 0 ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE �oI I 2 FIRE 0 IA 10U2 2 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I m 1234 E PRAIRIE BROOK DR A3 M ❑Y ®SYSNEM DUNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF & {I� 4 •COM VEH ❑ ® 1 O F JN1 DV6AR8CM861672 Geico ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same 6129 07 57 99 1 o HOSPITAL(TAKEN TO) INCIDENT ' IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L El Y El N 2 17 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 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) Demjk, Paul,G. 0mo day yr 0 1 9 5 2 Lexus ES350 2011 oo-NONEDA 13-UNDER CARRIAGE I11: 12 s REoCRASH ❑❑ ® U2 2 C v10 ', STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPUR 0 E 35W650 W REI DG EWOOD LN M SYSTEM IN 0 ion ENGAGED 0 15-OTHER O9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distract Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 9 T_II a l_5 C•IOMe6 3eeSidebaH ❑ ® U1 to C Z Saint Charles IL 60175 0 XPG DX IL 2025 REAR 0 nn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (708)363-3900 D520-6875-2113 IL D JTHBK1 EG3B2434742 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 0534475-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < REEl Y 0NR Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (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 El AM Did crash occur 0 Y U2 Z N ® 11 4 10/18 /2024 04 28 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 a 2 0 2 28 ! / 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 5 ® 11 4 ARREST NAME Garcia,Aaron 11-901-A 1534000081 / / ❑PM SLMT o u CICITATIONS ISSUED ElPENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N B AM 30 2 ❑ ARREST NAME , / ptil ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 1534-Santiago.Jorge 401 246-Kite 11 , 19/2024 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. 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 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 . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . 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 White Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE