HomeMy WebLinkAbout2024-00067415 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III )III III ll
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003556463
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
0 NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and JorTow Due To Crash YR 2024I2024-00067415 VENT *
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 'IT
ST CHARLES ST ❑Elgin RELATED ®Y ❑N 10 22 2024 07.19 ®AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT/MI N E S W DWIGHT ST COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR El SLOW 1 U)
❑ Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® 0 FREE FLOW # LNS 0
tg DRIVER 0 PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NMv ❑Nov ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
1 1 / 1 9 /1 9 9 6 FOR DAMAGEDAREA(S) FROM TOWED U1
Martinez,Christian. E. Freightliner Cdt 100 2024 00-NONE 11 ' DUE TO CRASH 0
NAME(LAST,FIRST,M) mo day yr 12
13-UNDER CARRIAGE 19 2 FIRE ❑ ® 4 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ISI 0 U2 m
774 BLUFF CITY BLVD M ❑Y ®SYSNEM DUNK VEH. 0 ATCRASH 99-UUTHER NKNOWN 9 76-TOP 3 •Distraction Value 5 ALGN I
T. CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH ❑ ® 3 O
~
3ALACWFC9RDUS4785 ACORD ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Arties 41-LX020474433-0 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER >
L RESPONDER
Y DEN 150 WOODVIEW DR. IL (847)888-0611 VEHU 0
®DRIVER ❑ PARKED ❑DRNERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NMv ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 13 m
m FOR DAMAGED AREA(S) FRONT TOWED Y N
s Friedberg, Pelelo e.J. 0 6 / 1 3 /1 9 6 0 Toyota Corolla 2019 00-NONE
13-UNDER CARRIAGE :1 O' DUEFIRE TO CRASH IN 2
NAME(LAST,FIRST,MI g• P mo day yr 10 12 I! s U2 C El [2]
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR 1)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X
E. 66 BRIGHT OAKS CIR F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN II •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF
FIRST CNT ONTACT 11 7_'1 6 �_5 C•IOMeSVSee Sidebar❑ ® U1
al
PEAR C
Z Cary IL 60013 0 BF90940 IL 2025 0 C
.11
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)962-6491 F631-6706-0768 IL D 2T1 BURHE1 KC178803 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 0394062-SFP-13 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
ERESPONDER
Y0
lSame U1 =
(UNIT) I SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 02 /07/1980 F 2 3 0 1 0 Erin Faille/1339 SUMMERSWEET LN,BARTLETT-IL-60103 Refused 996 ,-
(847)529-0173_ U2 m
/ / #OCCS D
XI
/ / UI 2 m
/ I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z
N 0 11 4 10/22 /2024 07 19 ❑pM in a Work Zone? ®N DIRP al
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 0 2 41 1 ( 0 PM 0 Construction >t
N 3 0 O CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
ARREST NAME Briseno Martinez,Christian. E. 11-901-A W1504000417 / / ❑PM SLMT
CO11 4 0 Utility
p u 0 CITATIONS ISSUED El PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME
',3N 8 AM 30
2 0 ARREST NAME / / ppl Unknown work zone type Ut
T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? El Y 30
1504 Real. Hilario 401 272-Bajak 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
; I 0 "
f A CMV is defined as any motor vehxae used to transport passengers or property and. D
e 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
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{ combination) or —I
, ', I r INDICATE NORTH XI
oi
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} J. J. ', i -` r r r (example.shuttle or charter bus)-or n
X
Is designed to carry 15 fewer passengers andoperated r 0
----?-----� L
-r } } } transporting rting employees in the course of their employment(example�emaployeerie 0
J �T 3. W Y
transporter-usually a van type vehicle or passenger car) or CO
I____A____: : ; ? 1 : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the diver,
I ) J I ( for direct compensation(example:large van used for specific purpose).or
L____--____; i 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) M
.11.01715. CARRIER NAME Z
ADDRESS0
O
CITY/STATE/ZIP
^ MOTOR CARR ID ❑ Interstate ElIntrastate
Not To Scale ❑ Not in Comm./Govt. ❑ Not m Comm./Other Q
^ USDOT NO. ILCC NO. m
, 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 D
Did Carrier Safety Regulations(MCS)violation contribute to the crash
❑ Yes 0 No ❑ Unknown 0
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 D
m
XI
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
D
TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ o
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 1 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE