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HomeMy WebLinkAbout2024-00066849 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIII lull 111111111111 11111011111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E415 u, 1 uz 1 99 9 1 U1 5 U2 1 ut 1 U2 1 U1 99 U2 1 1 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 7 [23 NOT ON S VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066849 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m SUMMIT ST ®gin ID ❑Y coN l O 19 2024 05'03 ❑AM ❑YES ®No u1 ,-‹ PRIVATE mo /day I yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING y #OF MOTOR ❑SLOW 1 U) ❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH ❑N VEHICLES INVLD IE STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 ERNERLESS ❑ PEo ❑PEDAL ❑EOUES 0 NIA/ ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 5 / 0 8 /1 9 8 2 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) . Lorenzo mo day yr Mercedes-Bermsprinter 2018 ®-NONE 11 12 O DUE To CRASH El vi 13-UNDER CARRIAGE 10 I , 2 FIRE ❑ ® 0 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ISI 0 U2 m 815 CARLTON DR M ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 76-TOP 3 •Distraction Value 9 ALGN 2 CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH ❑ ® 1 0 WD3PE8CD3JP613892 Pekin Insurance ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 005984496 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L El ®N 2 G) m ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑ECNEE 0 WV ❑Ncv 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED n NAME(LAST,FIRST,M) mo day yr Infiniti Q60 2014 00-NONE 1 ` 12 '_1 DUE TO CRASH ❑ ® 2 —I c 13-UNDER CARRIAGE Oj ! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 a SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X El 0 N ®UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value 9 UI 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH ❑ ® to C FIRST CONTACT 11 7__.1 8_5 •(ryes,See Sidebar DU18737 IL 2024 FEAR 0 fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JN1CV6EKOEM113641 SateFarm ❑Y ON RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 I Portillo- Diego. U. 2765920-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER 4 HIGHBURY DR. ELGIN . IL.60120 (224)245-7766 Ut = (UNITE i SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I{ADDRESS)i(TELEPHONE) (EMS) (HOSPITAL) 1 3 07 /1 8/2014 F 2 4 0 1 Lindy Andaya/815 CARLTON DR.ELGIN-IL-60120 U2 996 m I I #OCCS D / / u t 2 m I I 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ElY U2 Z N 0 18 5 10/19 /2024 05 08 ®pm in a Work Zone? El 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 0 T 2 0 06 18 ! / 0 PM El Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q 1 ® 11 5 ARREST NAME / / El PM • 0 Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 25 1 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 10 560-Martirez.Samantha 202 334-Fries , , ❑PM ®N U2 I 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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS . 0 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z "--r----, , 4 r r r r r , , , , . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r i ; i i ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L I ', ! t- t ' ' ' '. ', ' f ` 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------'-----• + + • : - 1 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 Hated to trans rt between 9 and 15 assen ers including the dr ver, 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. CARRIER NAME Z ' ADDRESS 0 D f/1 • • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. El Not in Comm./Other Q C r-----.-----, r r r r r•---, r - DO ILCC NO. m U N XI , Source of above Z . 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 White WhiteEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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