HomeMy WebLinkAbout2024-00067691 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II II I Ill
OIl
III 1In ll 1111111111111111111111111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602235
u, 1 U21 3 4 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
0 NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and JorTow Due To Crash YR 202412024-00067691 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �'1
RT20 WB ® ❑
Elgin RELATED ®Y ❑N 10 23 2024 02:31 ❑AM ❑YES ®NO U1
PRIVATE mo /day/yr ®PM FLOW CONDITION m
'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ®SLOW 15 N
050 0/MI OE S W Lambert Ln 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
AT INTERSECTION WITH fNAME OF ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS ' 0
tg DRNER 0 PARKED 0 ERNERLESS ❑ PEE ❑PEDAL 0 EOUES 0 SIN 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGED AREA(S) FPC1 43 TOWED
2 Ut O
, M. 12 / 01 J1 9 7 0 Maserati GTI series 2020 00-NONE 11 .I,z , DUE TO CRASH El — E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 1D 0 144-TOTAL(ALL) DISTRACTED 0 I U2 3 m
2629 CARDINAL DR F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP® ,Distraction Value 9 ALGN =
r POINT OF 9 1 O COM VEH 0 ® C)CITY PLATE NO. STATE YEAR 6 1
~
ZN661XUA5LX354951 West Bend Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
a 99 9 ALOI, ERLADO,A. hhb-8858458-00 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r
o RESPONDER 2629 CARDINAL DR. ELGIN - IL.60120 (630)333-7192 VEHU >
®DRIVER ❑ PARKED 0 ORNERLESS ❑ PEE ❑PEDAL ❑EQUES 0 KW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
m / J FOR DAMAGED AREA(S) FRONT TOWED �Y N
s Carlson. Logan,A. 1 1 3 0 2 0 0 6 Mitsubishi Outlander 2012 00-NONE O' i'O DUE TO CRASH Id 0 2 -I
, NAME(LAST,FIRST,M) g mo day yr Q,
I', t3-UNDERCARRIAGE 10 fj 2 FIRE ❑ ® U2 C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X
a` 358 CORNWALL AVE M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN II •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T IOONTACT 1 7F _'1 6 1_S C•IOMeS See SidebarH ❑ Igl U1 to
ZSOUTH ELGIN IL 60177 0 2951688 IL 2024 I0 n
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(815)919-6426 C642-5210-6340 IL D 0 JA4AS3AW1 C0007520 ALLSTATE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I
99 9 Carlson. Ricky-S. 975214874 BAC ' 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
pO®N 358 CORNWALL AVE.SOUTH ELGIN . IL.60177 (815)919-6426 U1 =
iUNIT i SEAT) i DOBi (SEX, (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME IIADDRESSi/iTELEPHONEI (EMSi (HOSPITAL)
2 3 09 /20/2006 M 2 8 0 1 0 DEMITRI J. MOSTACCI/287 HICKORY LN-SOUTH ELGIN,IL,60177 996 r
(630)303-2811 , U2 m
/ / #OCCS D
/ /• U1• 1 m
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑v U2 Z
N 23 11 1 10/23 /2024 02 31 ®pM in a Work Zone? ®N DIRP co
1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 3
T 2 ❑ 28 06
! / 0 PM 0 Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
CO 11 1 ARREST NAME Aloi.Cristina, M. 11-601 485000310 / / El PM SLMT
o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N 8 AM 45 1
rr T
2 0 ARREST NAME r / ppl ❑Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑ Workers present?
485-Quintana.Josue 401 - / / ❑PM ® 45
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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
' r } A CMV is defined as any motor vehicle used to transport passengers or property and. Z
r-
"--r----, , 1 r r r r r , , , , .
01 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
r"0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ', ! i. L ' ' 1 ', ' 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------i-----• + + • : - -, 1 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
`
CARRIER NAME Z
' .. ADDRESS 0
N
CITY/STATE/ZIP 0
. - MOTOR CARR ID ❑ Interstate El Intrastate
❑ Not in Comm./Govt. ElNot in Comm./Other Q
m
r-----.-----, r r r r r•---, r '- DO ILCC NO. m
U N XI
, Source of above Z
). Form Number m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
' TRAILER VIN 1 N
LOCAL USE ONLY TRAILER VIN 2 m
TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m
m
TRAILER 1 ❑ ❑ ❑ Z
TRAILER 2 ❑ ❑ ❑ o
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Black Gray
-
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ 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 zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE