HomeMy WebLinkAbout2024-00067294 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 1111111111111111101111111111111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O3556446
u, 1 U2 1 3 4 1 U1 2 U2 1 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 SCENE 14
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00067294 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT
BIG TIMBER RD ® ❑
Elgin RELATED ®Y ❑N 10 21 2024 04:22 ❑AM ❑YES ®NO U1 .(
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E 5 W N RANDALL
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑ECUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 6 / 1 7 /2 0 0 7 FOR DAMAGED AREA(S) FRONT TOWED U1
,Alex Ford F150 2007 00-NONE 0..7z.,/1 DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE lJ FIRE ❑
IA
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 El U2 0 m
334 4 WINDS WAY M ❑Y INS NE
❑UNK VEH. O SYTM AT CRASH D 0 15-99-UUNKNOWN THER9 16-TOP 3 ,Distraction Value 9 ALGN =
T. CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH ❑ El1 O
I— FIRST CONTACT 12 7_7I Q:_.5 'Y Yes,See Sidebar U1
Z
1 FTPW14V37KA87285 StateFarm ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Rodarte Sanchez,Antonio 0145970-SFP-13 1
r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER
y°®EN 334 4 WINDS WAY,Carpentersville. IL.60110 VEHU GI
GI
®DRIVER ❑ PARKED 0 ORNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 KW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
m / / FOR DAMAGED AREA(S) FROM TOWED Y N
5 NAME(LAST,FIRST,M) Petersen.Jack, E. Imo �ay 1 9 5 1 Hyundai Santa Fe 2023 oo-NONE O' 1$ y DUErocRasH 0 2 Xi
v yr 13-UNDER CARRIAGE 9 i I! 2 FIRE ❑ ® U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 IN SPOR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X
E. 2020 MONDAY DR M ❑Y (2/ N ❑UNK VEH. AT CRASH 99-UNKNOWN 'OistracoonValue
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO
P RI8T NT COONTACT F 11 7_'1 8 1_5 C•IOMeeVSee ❑ ® U1
I- to
ELGIN IL 60123 0 PTRSEN 1 IL 2025 REAR Sidebar
9 Sn
Z
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)529-3762 P362-4255-1312 IL M 0 5NMS3DAJ5PH632081 Statefarm ❑y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 1878918-SFP-13 Bnc , 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
y°®N Same Ut =
(UNITE (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMSi (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 POUCE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
N ® 11 4 10/21 /2024 04 22 ®pM in a Work Zone? ®N DIRP D
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7
2 ❑ 2 50 10/21 /2024 04 22 ®PM ❑Construction *
N T 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
CO 11 4 ARREST NAME Rodarate,Alex 11-901-A S1537-000014 10/21 /2024 04 27 ®PM SLMT
o u CITATIONS ISSUED PENDING ROAD CLEARANCE TIME . 0 Utility
o N SECTION CITATION NO. AM 45 1
2 0 ARREST NAME 10/21 /2024 05 05 El RA0 Unknown work zone type Ut
T
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1537-Mapp,Teddron 500 - 11 , 12/2024 09 00 p 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.
_ 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
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r 1 - combination) or 'I
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L 1 ', ' -! ` r r r (example.shuttle or charter bus)-or
N Not To Scale
r 1) i I i I i designed to carry 15 or fewer passengers and operated a contract carrier 0
. i .
---- ----% + f } } t transporting employees in the course of their employment(example employee ZI
transporter-usually a van type vehicle or passenger car).or w
i____A____: 4 algrmicsnRd i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N
—_ — — for direct compensation(example.large van used for specific purpose).or O
L____L____4 ; , �r i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
�_ ' ` ,�, placarding(example placards will be displayed on the vehicle) 71
CARRIER NAME Z
ADDRESS N
. "
_ ,_ .. ... . .
711 . 1 . 1 . .
. . • CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
: • 0 Not in Comm./Govt. Not in Comm./Other
USDOT NO. ILCC NO.
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
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 Gray
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO.
DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE