HomeMy WebLinkAbout2024-00067967 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OII
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003599106
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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 14
0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and JorTow Due To Crash YR 2024I2024-00067967 VENT *
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'rl
S MELROSE AVE Elgin ID
®Y ❑N 10 24 2024 06:49 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W ERIE ST 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 15 N
❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NMV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGED AREA(S) FRONT TOWED Ut
NAME(LAST,FIRST,M) .JOSE mo Nissan Sentra 2015 00-NONE
0
/ day J yr 0 Q O DIJE TO CRASH ® ❑
13-UNDERCARRIAGE FIRE ❑ IA
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 El U2 0 m
21W551 NORTH AVE M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value 9 ALGN =
W. CITY PLATE NO. STATE YEAR POINT OF 8 j 4 COM VEH 0 ® 1 0
FIRST CONTACT 12 7 ? 6 :_.6 ^Yves,See Sidebar U1
"2 2Z
3N1AB7AP5FY286061 AMERICAN ALLEGIANCE ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Same I LAA-0897530-01 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >
'' RESPONDER Same VEHU 73
L ❑Y ®N 98 G-)
®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEGS. ❑EQUES 0 WV ❑NCV 0 ov U1
DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N m
m / 1 J FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Brunner,Jacklyn.O. 0mo day 2 0 yr 0 0 Ford Edge 2010 00-NONE 13-UNDER CARRIAGE Oi 12.i y Z Xi
C
FIREEToCRASH O 0 C
U2 2
c _STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® SPDR n
SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 9 0 X
a` 12 S ALDINE ST F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN I •DistractionValue
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 9 ®) 6 1_S C•IOMe6 Bee SidebaH r Igl U1 to
H ELGIN IL 60123 0 CT27034 IL 2024 REARf 0
Sn
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)713-4446 B656-4340-0741 IL D 0 2FMDK4KC9ABA73292 GEICO ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Same 6142198024 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
Y NR Same U1 =
(UNIT) (SEAT) (DOBi (SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
I I - U2 996 1-
m
- #OCCS y
/ /• U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z
N ® 11 4 10/24 /2024 06 49 ®pm in a Work Zone? ®N DIRP D
1 I 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 18 ! / 0 PM 0 Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
Q CO 11 4 ARREST NAME SANCHEZ.JOSE 11-901-A 1542-000022 / / ❑PM SLMT
o U CITATIONS ISSUED PENDING ROAD CLEARANCE• TIME ❑Utility
o N SECTION CITATION NO. AM 30
2 0 ARREST NAME 10/24 /2024 07 30 ®PM 0 Unknown work zone type U1
T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1542-Chace. Uze. Ethan 601 334-Fries 11 / 19/2024 09 00 0 pM Workers present? 30
30
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
. , . " 0
ADDITIONAL UNITS FORMS
0 >
_ } A CMV is defined as any motor vehicle used to transport passengers or property a
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
{ combination)or —I
r '1 1 , Not To Scale INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ', d i -` ` r r r (example.shuttle or charter bus)-or n
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------;-----% 1 -i } - i- transporting employees in the course of their employment(example.employee M
-usually a van
vehicle or
ca
:.____A____: : , - r i 4transporter
suosedrordesgnatedto rransportbetween9and 15rpassengers,indudingthedriver, C
II--
,�— for direct compensation(example.large van used for specific purpose).or O
___I 1 ; , — I i ) i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I placarding(example placards will be displayed on the vehicle) n
—O\ ® CARRIER NAME
ADDRESS 0
O
CITY/STATE/ZIP
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. ElNot in Comm./Other Q
USDOT NO. ILCC NO. m
, Source of above z
. 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
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y
Gray Gray
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Arties/Impound Lot Garage 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