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HomeMy WebLinkAbout2024-00066399 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 10 Sheets II II I III DIII III 1001lu ll 1111111111111111 111111110111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO3599017 u, 1 U21 1 1 1 U1 5 U2 1 U, 1 U2 1 U1 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$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 [23 NOT ON S VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00066399 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 m SHERWOOD AVE Elgin El ❑Y coN 10 17 2024 02_20 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ®PM FLOW CONDITION m Ell 09,/MI N E O W Northwest ) PEDALCYCUST El [] FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n O International0GainE 2016 00-NONE D,IETOCRASH NAME(LAST,FIRST,M) .Alicia. N. mo day yr 11- 12 -1 0 2113-UNDERCARRIAGE 19)• 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I U2 2 m 646 JAY ST F ❑Y ISYNM❑UNK VEH. O AT CRASH D O 99-UUTHER NKNOWN O9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 ),1 e l 4 COM VEH 0 ® 1 O a ~ 4DRBUC8N5GB16511 Self Insured ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 99 9 School District U46 Self Insured 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPOND E ER N 500 SHALES PKWY. ELGIN . I L.60120 (847)888-5000 VEHU X m 0 DRIVER ® PARKED 0 ORNERLESS 0 PEE ❑PEDAL ❑EOUES 0 RUN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 7 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Mitsubishi Outlander 2023 oo-NONE 12 y DUE TO CRASH ❑ ® 1 c 13.UNDER CARRIAGE Oi II z FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPDR n ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 4 •Distraction Value 9 U1 0 - — POINT OF N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR II COM VEH ❑ ® C H FIRST CONTACT 11 7__.1 8_5 •(ryes,See Sidebar L981911 IL 2025 1 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JA4J4UA82PZ009299 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 9 Castaneda. Daniel.A. 2052541-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 1146 IROQUOIS DR. ELGIN . 11_60120 (847)525-8521 U1 = (UNIT) i SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME!((ADDRESS)(;TELEPHONE) (EMS) (HOSPITAL) 1 7 10 /1 5/2012 1 3 0 1 Jackie Segovio/1260 CHRISTOPHER CT.Elgin,IL,60120 Refused 996 ,- (224)238-9060 , U2 m 1 7 10 /1 0/2012 1 3 0 1 Cooper Kalbach/1270 COBBLERS CROSSING-ELGIN.IL-60120 Refused #occs y (360)363-6673 _ 1 7 06 /29/2013 F 1 3 0 1 Mia Abarca/145 DICKENS TRL.ELGIN,IL,60120 Refused U1 21 m (84 717 08-1 5 6 9 D 1 7 11 /15f2013 1 3 0 1 Khariylah Iawrence/1213 APPLE LN-ELGIN-IL-60120 (773)637-4034 Refused 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N 1 ® 18 1 10/17 /2024 02 20 0 pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM I1 YES check one below: U1 7 C) T 2 ❑ 06 99 ! / ❑PM ❑Construction * t cs 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 1 El 11 1 ARREST NAME / / ❑PM< ❑Utility SLMT p U ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 ❑ ARREST NAME r / PM ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 0 AM Workers present? El Y 25 1540-Allah. Muhammad 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 ' } 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 '. ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 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 O 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----, r '- DO ILCC NO. m U N 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? ID 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 Yellow Black - 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