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HomeMy WebLinkAbout2024-00066860 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III HI IIIIIII II 111111111111111110111111 II 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593 33 u, 1 U2 1 3 4 1 U1 4 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 2 0 NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066860 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I N RANDALL RD ®gin El ❑Y coN 10 19 2024 05:51 ❑AM ❑YES ®No u1 • ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 1 0 /MI N E W North Higgins ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N 0FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EOUES 0 NW Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 1 0 / 2 0 J 1 9 9 2 FOR DAMAGEDAREA(S) FRO TOWED U1 O D,IETOCRASH NAME(LAST,FIRST,M) ,JacuindesChevrolet Cruze 2014 00-NONE DI M Zavala mo day yr 11-1 12 D El -UNDER CARRIAGE 10 I <i 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 4 m 826 BALTUSROL DR M SYM DY INN DUNK VEH. O AT CRASHD 0 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 i1 6 ii-4 COM VEH 0 ® 1 0 a ~ 1 G 1 PC5SB5E7481789 American Alliance ❑v ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same ILAA098501200 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCV 0 Dv 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) Smith, Monica,A. Omo day 1 9 6 6 Honda CRV 2018 00-NONE 11, 12 Y REocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE I.- c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 a 1171 MILLCREEK LN F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5�I����/���r 4 COM VEH ❑ ® U1 1— FIRST CONTACT 6 7_•d_ t'w•If Yes,See Sidebar Z Algonquin I L 60102 0 ENR712 IL 2025 REAR 0 f0 2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)344-1892 S530-5416-6656 IL D 0 7FARW2H95JE066281 Nationwide ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 9112J076272 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N 181 Same Ut 2 (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMSI (HOSPITAL) I I - uz 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 ❑AM Did crash occur ❑Y U2 Z N 1 ® 11 1 10/19 /2024 05 51 ®pm in a Work Zone? El 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: U1 1 C) T 2 0 28 99 ! / 0 PM ❑Construction * c' 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q • ARREST NAME Jose Antonio,Jacuindes Zavala 11-601 1500000285 / / ❑PM SLMT o N , ® 11 1 ®CITATIONS •ISSUED ElPENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility 50 T 2 0 ARREST NAME Jose Antonio.Jacuindes Zavala 6-101 1500000286 10/19 /2024 06 41 ®PM 0 Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1500-Chew, Marie 901 334-Fries 11 / 18/2024 09 00 0 PM Workers present? 0 N U2 50 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 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS 4 } 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 i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C '. ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 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 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 P3 73 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? ID 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 Gray Gray - 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