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HomeMy WebLinkAbout2024-00066798 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III OII III 1III1011 lIOfl IHO I SDI IDS1111��1, I Ill 1II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003599104.1111 u, 1 U210 1 1 1 U116 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 9 Ut 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 7 El NOT ON S VEHICLE/PROPERTY ElOVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066798 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 S RANDALL RD ® ❑ Elgin RELATED ❑Y coN 10 19 2024 01:37 ❑AM ❑YES ®No ut -< PRIVATE mo /day I yr ®PM FLOW CONDITION m 1 0 /MI N E S W Spartan Dr COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ❑SLOW 1 N Nil ICJ O ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NIA/ ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n 0 2 / 1 1 J2 0 0 7 FOR DAMAGEDAREA(S) FRONT TOWED Ut Chevrolet Malibu 2009 00-NONE /�D,IE TO CRASH 21 NAME(LAST,FIRST,M) , David mo day yr 11-i 12 ❑ 13-UNDER CARRIAGE IA 10 I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 00 m 1105 HIGHBURY DR M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH 0 El 1 0 a ~ 1G1ZJ57B49F184676 Statefarm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Hernandez. Maria 2790131-SFP-13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 1105 HIGHBURY DR• ELGIN . 11_60120 (224)659-4064 VEHU G1 m 0 DRIVER ® PARKED 0 CRNERLESS ❑ RED ❑PEDAL ❑EQUES 0 NMV ❑soy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGEDAREA(S) FRONT TOWED Y N s Hyundai Elantra 2019 00-NONE 1 1 DUE TO CRASH ❑ ® 1 , NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE of 12.i_2 FIRE ❑ ® U2 C v STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 0 IN SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 U1 0 POINT OF 6O ` 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 _ COM VEH ❑ H FIRST CONTACT 15 Z O7 1 5 It ves,See Sidebar C DL13820 IL 2025 R • 21 0 I;p M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5NPD84LF1 KH412158 American Alliance Magnum ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 9 Martinez. Laura. I. II.AA-0890116-01 BAC , 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ONDE 0 Y NR 430 CORNELL LN - ELGIN . IL.60123 (331)308-6089 U1 = (UNIT( (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) n I I U2 996 r m / / #OcCS ' D / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur CI Y U2 Z N ® 18 1 10,19 /2024 01 37 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 It YES check one below: U1 3 C) T 2 0 15 99 ! / 0 PM El Construction * N 1 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM El Maintenance U2 3 1 ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME "'p N B AM 15 T 2 0 ARREST NAME I I ptil ❑Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? ❑Y 15 1509-Wortman.Cassie 702 246-Kite I / p 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 "--r----, , 4 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i- L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; 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 M 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP n , , • . - MOTOR CARR ID ❑ Interstate ElIntrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r•---, i - DO ILCC NO. m U N XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Gray 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE