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HomeMy WebLinkAbout2024-00067449 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I III ll II 111111111111 IIIII 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X00355E453 u, 1 U2 1 1 1 1 U199 u2 1 Ut 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 11 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 11 El NOT ON VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067449 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'T'I RT20 WB Elgin ❑ RELATED ❑Y coN 10 22 2024 10:52 ®AM ❑YES ®NO U1 -< PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W S STATE ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U1 ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH /NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' Q tg DRIVER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / J Ford F150 2014 00-NONE FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) ,T. mo day yr ti QI _1 DUE TO CRASH ❑ 13-UNDERCARRIAGE tD21 I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10U2 4 < 1713 PEMBROOK CT M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 T. / ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN F 8 4 'Distraction Value ALGN CITY PLATE NO. STATE YEAR FIRST CONTONTACT 12 6 -:_6 CIOMYe$See SidebaEH ❑ ® U1 1 0 c Z 1FTEX1CM6EKE37972 Zurih American Insurance ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a IHC Construction Company bap508483603 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER 1500 EXECUTIVE DR, ELGIN , IL,60123 (847)742-1516 VEHU 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUN ❑Ncv 0 Du DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 14 m N / J FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) AvareZ, Eelm,Y. 1 2 lday yr 2 0 0 4 Toyota Camry 2019 oo-NONE +c I 12 ' s ReoCRASH ❑❑ ® U2 2 C c 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 a 39 WASHINGTON AVE F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j all! 4 COM VEH ❑ ® U1al FIRST CONTACT 6 __ 5 •If Yes,See Sidebar Z 7 Streamwood IL 60107 0 BG18738 IL 2025 REAR 0 CCC>, D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)788-2456 A416-2190-4958 IL D 4T1 B61 HKXKU803540 all state ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Alvarez. Miguel.a. 811361177 BAC ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER UN 39 WASHINGTON AVE.Streamwood, IL,60107 (630)335-4640 U1 = (UNIT( (SEAT) (DOB) ISEX) ISAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) I I U2 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 CD U2 Z N ® 11 1 10,22 /2024 10 52 ❑pM in a Work Zone? ❑N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 7 C) T 2 ❑ 28 03 ! / 0 PM inConstruction * EN 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Gul,Jonathan.T. 11-601 1545000021 / / ❑PM SLMT o U ❑CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N IIAM 55 2 El ARREST NAME I / ptil Ut ❑Unknown work zone type 1,1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ®Y 55 1545-VanEycke, Brier 701 272-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. 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 ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or 0 S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------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 0 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 El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - 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 PJ 7) 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? JD 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 White Silver - 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