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HomeMy WebLinkAbout2024-00067194 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III )III )IIIIII II 1111111111111111 IIIIIIIIIIIIIIIllII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO3599 1 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15 El NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and/or Tow Due To Crash YR 2024I2024-00067194 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 -F'I WALNUT AVE ® ❑ Elgin RELATED ®Y ❑N 10 21 2024 07:15 ®AM ❑YES ®No u1 -‹ PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W J EWETT ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑AIN ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 4 / 2 6 /2 0 0 7 FOR DAMAGEDAREA(S) FRONT TOWED U1 . Natalie, M. Acura MDX 2006 00-NONE „ 12 , DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE �0 I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 l U2 0 m 430 ENTERPRISE ST F ❑Y El NSYSTEM DUNK VEH. 0 ATCRASH 99-UUTHER NKNOWN O9 16-TOP 3 •Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 ® 1 0 A ~ 2HNYD18206H510172 GEICO 0Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 6170748856 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 KW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FR 4T TOWED s Rojas.Sofia 0 2 2 4 2 0 0 8 Ford Mustang 2003 00-NONE 1t i'_, DUE TO CRASH (g 0 2 —I NAME(LAST,FIRST,M) mo day yr ©, I', 13-UNDER CARRIAGE �I Ij FIRE ID ® U2 XI ��STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) C z DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a 358 WABASH ST F ❑Y MIN ElUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO P RI8T NT COONTACT F 12 7_'1 a 1_5 C•IOMe6V S ee Sidebar❑ ® U1 to H ELGIN IL 60123 0 CT35790 IL 2025 0 P D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (331)901-9478 R220-7800-8655 IL D 0 1 FAFP44403F314586 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 0196672-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNIT) I SEAT) (DOB) (SEX, ;SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMSi (HOSPITAL) 2 3 07 /09/2008 M 2 8 0 1 Jose D. Espinoza/361 ELM ST.ELGIN.IL.60123 - 996 r (331)588-0821 , U2 m / / #OCCS D / / • UI 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 10/21 /2024 07 15 ❑pM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5 — 2 0 2 18 ! / 0 PM ❑Construction * N T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q •CO 11 4 ARREST NAME Mueller. Natalie, M. 11-901 499000722 / / El PM SLMT o u ❑CITATIONS ISSUED •❑PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N II AM 45 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 499-Dirck Cameron 701 272-Bajak / / 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. F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A A. ADDITIONAL UNITS FORMS A I ; I Irl _� } A CMV is defined as any motor vehicle used to transport passengers or property and. Tx Not lb Scab j 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z , r I I ; ; INDICATE NORTH combination)or —I XI I I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. I d i @S I -t ` r r r (example'.shuttle or charter bus)-or X 1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 ---- ----� I f ) } } } transporting employees in the course of their employment(example employee M transporter -usually a van nvehicle or car). �_ _ A____: . , T.., NelnrtraMe i i Na for direct compensation(example large van used for specific purpose).or O L____-:_____; i ; , — — — 7--- _t t y } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' t ADDRESS 0 N • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. • , Source of above 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? O ❑ 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 Form Number 0 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 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 Gold Silver - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO- SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE