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HomeMy WebLinkAbout2024-00067148 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III )III IIIIIII II 111111111111111110111011110111 MI II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O35.359r u, 1 U2 1 1 1 Ui 4 U2 U, 1 U2 UI 1 U2 4 6 Ut 1 U2 *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 SCENE 2 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067148 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I RT20 EB ®gin El ❑Y coN 10 20 2024 09:45 ❑AM ❑YES ®No u1 • -< PRIVATE mo /day I yr ®PM FLOW CONDITION m E150 ®I MI N 0 S W GRACE St 'COUNTY PROPERTY ElY ®N DOORING ❑Y #OF MOTOR ❑SLOW CI) Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS ' 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n Hteta TOWED U, O NAME(LAST,FIRST,M) . LEONARDO mo day yr Honda Civic 2006 00-NONE ©' .IO..0 DUETOCRASH El ,3-UNDERCARRIAGE 10 z FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 m 110 9TH AVE M ❑Y ®SYSNEM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP® Distraction Value 5 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 6 i l 6 O COM VEH 0 ® 1 n 1HGFA16526L047264 NO INSURANCE ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same NO INSURANCE 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU o ElY ❑N 2 0 7S7 ❑DRIVER ❑ PARKED 0 DRNERLESS ❑ PED 0 PEDAL ❑EOUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m a / / FOR DAMAGED AREA(S) FRONT TOWED fi ' 1 DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 1t 12 71 c 13-UNDER CARRIAGE 101 j 2 FIRE ❑ ❑ U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR C) a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 •Distraction Value UI 9 POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7_II 6I_s C•IOMe68eeSideba❑ 0 C to 1- FEAR C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 2 BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < RESPONDERlY U, 2 (UNITE I SEAT) i DOB' (SEX) ISAFTI (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'r-fADDRESS)7 iTELEPHONEI (EMS) (HOSPITAL) n 1 3 01 /07/2002 F 2 3 0 1 0 KALYN A. VENCES/6770 PEACH TREE ST.Hanover Park.IL.60133 U2 r (630)998-1140 , m / / #OCCS D • / / u1 2 m I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N �� 43 1 10 r 20 /2024 09 45 ®pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 3 T 2 ❑ 28 99 ! / PM ElConstruction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME z ❑AM ❑Maintenance U2 ARREST NAME MONTOYA. LEONARDO 11-601 1516000451 / / El PM SLMT o U 1 0 El CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N AM 55 2 0 ARREST NAME MONTOYA. LEONARDO 3-707 1516000452 / / 8 ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 2 3 El 1516-Mancera. Maria 401 11 r 19/2024 09 00 0 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. Tx Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I 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 '- I ', ' -t ` r r r (example.shuttle or charter bus)-or n X i............4 4 F tI i 3 Is gslpassengersmex � a carrier transporting employees the course of their (example employee M transporter -usually a van C i.____-:----_: : , !' i r i 4 sedor des gnated to transportr between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose).or 11 L____-L___-; ; . , an - i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires rn placarding(example placards will be displayed on the vehicle) 71 T. 9y'�°n° CARRIER NAME ' t ADDRESS 0 0 Not A CITYISTATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate Q 0 Not in Comm./Govt. ❑ Not in Comm./Other Q USDOT NO. ILCC NO. C XI , Source of above Z • . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr 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 El Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft Z Black - U 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO © DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE