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HomeMy WebLinkAbout2024-00067327 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II 111111111111 11111011111 III 11111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E465 u, 9 uz 1 2 4 1 Ui 3 U2 1 U199 U2 1 U1 99 U2 1 1 10 Ut 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 2 0 NOT ON VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067327 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 71 FORESTAVE ❑Elgin RELATED ®Y ❑N 10 21 2024 06:06 ❑AM ❑YES ®NO U1 .< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W PRESTON ) Kane HIT&RUN (23Y ElN PEDALCYCUST®N ❑ FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut . Unknown.0. / / Unknown Unknown DO-NONE ®i ©I , DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ,9 ' 2 DIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 21 2 m IN ENGAGED3 UNKNOWN UNKNOWN ❑Y IN NEM❑UNK VEH. n AT CRASH 0 99-UNKNOWN THER 89 �6 TOP 4 'Distraction Value 9 ALGN .. T. CITY PLATE NO. STATE YEAR POINT OF 6 li COM VEH ❑ El 1 0 A ~ UNKNOWN Unknown ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y 99 9 Same Unknown 1I— m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L • ❑Y ®N 99 0®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m FOR DAMAGED AREA(S) FRONT TOWED 5 NAME(LAST,FIRST,M) BLANCO. RAUL 1 0 / l J mo day yr 6 1 9 6 1 Chevrolet Cruze 2014 00-NONE it. ©1'D DUE TOCRASH ❑ 212 c 13-UNDER CARRIAGE �0 1 Ij 2 FIRE El ICI U2 C :a' STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) Y E 56 HIGHBURY DR M SYSTEM IN O ENGAGED 0 ®-OTHER 9 16-TOP 3 ❑ ® ❑UNK VEH. AT CRASH 99-UNKNOWN 6I 4 'Distraction Value g cgiUt 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST NT OONTACT 12 7_'1 a I_5 C•IOMesVSee SidebaO al ~ E LG I N IL 60120 0 CG97490 IL 2024 REAR 0 CCn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)305-7639 B452-7206-1295 IL D 0 1 G 1 PCSSBXE7220786 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 811782774 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER N El Same Ut = (UNIT' (SEAT) (DOBi ISEX) (SEPT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - '#OCCS > 1 / / U1 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 23 11 1 10/21 /2024 06 06 ®pm in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: Ut 7 C) T 2 0 23 28 ! r 0 PM 0 Construction * r' 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 3 Q 1 ® 11 1 ARREST NAME / / 0 PM ❑Utility SLMT p U CI CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 El ARREST NAME r / ppl ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 485-Quintana.Josue 202 334-Fries I / ❑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. _ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS _� r A CMV is defined as any motor vehxae used to transport passengers or property and. D Z : ' 41.. I 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ` 1 , N I INDICATE NORTH I combination) or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver XI i_ ; t Not To scare J I -I. r r r (example.shuttle or charter bus)-or FathM1YN• JO i 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t------;-----� 4 - ` -f i- - )- transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_____......--_: : i , — — 'Unit2 — — — — — r , 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C ..i for direct compensation(example:large van used for specific purpose).or O L____-L___-; , _ i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires ♦�a�, �. �t placarding(example placards will be isplayed on the vehicle) 11 I 1 E . CARRIER NAME Z ADDRESS '� 0 . . . cn F CITY/STATE/ZIP r • , MOTOR CARR ID ❑ Interstate ❑ Intrastate : 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. XI , Source of above Z ). 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 Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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