HomeMy WebLinkAbout2024-00067891 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III )III IIII lull
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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 15
0 NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00067891 VENT
ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 11
WAVERLY DR ® ❑
Elgin RELATED ®Y ❑N 10 24 2024 02:54 ❑AM ®
❑YES NO u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
1 COUNTY PROPERTY El ®N DOORING 0 y #OF MOTOR CI 2 U1
® ®/MI N E S® Shiloh Ln WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEI ❑PEDAL ❑EOUES 0 Nav ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FRONT TOWED Ut 0
. L. 0 2 / 1 8 /1 9 6 5 Subaru XV Crosstrek 2.0 2024 00-NONE ®i 1$11 , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE fm
10 2 DIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El U2 0 m
77 W LYNN ST F SYTM❑Y ®SNE 0 UNK VEH. 0 AT CRASH 99-UUNKNOWN 9 16-TOP 3 ,Distraction Value 5 ALGN =
CITY THER
El
PLATE NO. STATE YEAR POINT OF 6 it ji 4 COM VEH 0 ® 4 01— FIRST CONTACT 1 7 rt 6"__6 "I(Yes,See Sidebar U1 0
Z
JF2GUADC1 RH203640 Liberty Mutual ❑Y ®N U2 m
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
Y Same A0V2437118764039 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 G1
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUM ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m / J FOR DAMAGED AREA(S) FRONT TOWED Y N
s Rodriguez. Esteban 1 2 2 6 1 9 5 1 Nissan Frontier 2010 00-NONE O' , DUE TO CRASH (g 0 2 —I
, NAME(LAST,FIRST,M) g mo day yr 10:1 12 I! Y FIRE ❑ ® U2 C
c 13-UNDER CARRIAGE
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
a` 61 H I G H BU RY DR M
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X
❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value
to
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RIST CNT OONTACT 1 T_II a 1_s F •CIOMe6VSeeSideba❑ ® U1
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~ ELGIN IL 60120 0 3065376B IL 2025 REAR 0 CCn
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)489-9651 R362-2005-1367 IL D 0 1 N6AD0EV8AC419935 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 811800852 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
Y NR Same Ut =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS Si WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS, (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z
N ® 11 1 10,24 /2024 03 00 ®ppt in a Work Zone? El N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1
2 0 41 50 10,24 /2024 03 00 ®pm 0 Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
AM ❑Maintenance U2
CO 11 1 ARREST NAME Certain.Jennifer. L. 11-1127-H- S1537-000015 10/24/2024 03 05 ®PM SLMT
p U CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME ❑Utility
o N SECTION CITATION NO. AM 30
2 0 ARREST NAME 10/24 /2024 03 40 EllpM 0 Unknown work zone type Ut
T
2 2 3 El El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? El 30
1537-Mapp,Teddron 200 - 11 , 12/2024 09 00 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
ADDITIONAL UNITS FORMS
; I _r r A CMV is defined as any motor vehxae used to transport passengers or property and.
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
r ; ; N _; ; INDICATE NORTH combination)or —I
XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
I ', i -! I. r r r (example.shuttle or charter bus)-or
,
',,el_ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
.
;,,f,
-----;-----• - -t t } t transporting employees in the course of their employment(example employee
transporter-usually a van type vehicle or passenger car).or w
i_____A____: : , I I : : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C
1 1 for direct compensation(example.large van used for specific purpose).or
O
11
L____......___; p i ) i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
•� placarding(example placards will be displayed on the vehicle) Zml
CARRIER NAME Z
ADDRESS 0
. Shiloh?Ln '1 ll N
I • CITY/STATE/ZIP
Not To Scale MOTOR CARR ID ❑ Interstate ❑ Intrastate
Waverty?Dr 0
I ❑ Not m Comm./Govt. ❑ Not m Comm!Other O
USDOT NO. ILCC NO. m
, Source of above Z
. If Yes, Name on placard O
4 digit UN NO. 1 digit Hazard class No M
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 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 C
Z
Form Number 0
m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
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 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 2
ft. y
Gray Red
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