HomeMy WebLinkAbout2024-00068373 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 010 III )III IIII lull 111111111111111
111011 0111110 II
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2319'
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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 •
1
0 NOT ON S
VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00068373 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 't'I
HIAWATHA DR ®gin ID
❑Y coN 10 26 2024 06:02 ❑AM ❑YES ®NO U1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
/MI N E S w Cooper Ave 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U)
235 ® O p CookT HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0
tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
06 / 0 4 /1 9 9 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut
mo day yr
13-UNDERCARRIAGE FIRE ❑ IA
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1D O DISTRACTED 0 1l U2 02 m
2154 VERNON DR M SYM
❑Y ®SNE❑UNK VEH. O AT CRASHD 0 99-UNKNOWN 9 16-TOP�3 ,Distraction Value 9 ALGN 2
CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii• 4 COM VEH 0 ® 1 O
FIRST CONTACT 1 7__.I REAR
5 •YYes,See Sidebar U1 0
E. Z
2C4RDGEG5JR299101 NIA ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
a 99 9 Herrera. Domingo NIA 1 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER L ❑Y ®N 2 1114 ASH DR 2e- ELGIN . IL.60120 VEHU
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NW ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m
m FOR DAMAGED AREA(S) FRONT TOWED Y N
5 NAME(LAST,FIRST,M) Morales, Hector, M. I 1 /mo day /2 0 0 4 Acura TL 2006 oo-NONE 0' 1$I.D1 DUE TO CRASH 0 2Xi
yr
13-UNDER CARRIAGE 101 I 2 FIRE ❑ ® U2 C
I', STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0
E 929 HILL AVE M ❑Y ® N 'DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 jI 6 ii 4 COM VEH ❑ ® U1to
H FIRST CONTACT 1 4_-1 5 •If Yes.See Sidebar
ELGIN IL 60120 0 DQ73427 IL 2024 REAR 0 CC11
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)977-6736 M642-3330-4331 IL D 0 19UUA66236A000055 State Farm ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Same 0691392-SFP-13 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
Y NR Same Ut =
(UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EldSi (HOSPITAL)
I I - uz 996 1-
m
/ - #OCCS D
/ /• U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z
N 1 ® I 1 1 10,26 /2024 06 02 ®pm in a Work Zone? El 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 1 C)
T 2 0 20 28
! / ❑PM ❑Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
Q •® I 1 1 ARREST NAME Mazariegos Perez.Arim. E. 11-601-Ax S1538000013 / / ❑PM SLMT
o U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
NAM 30
2 0 ARREST NAME Mazariegos Perez,Arim, E. 3-707 S1538000011 r / 8 ptil ❑Unknown work zone type Ut
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? D Y 30
1538-Estrada, Leticia 200 - 11 r 12/2024 01 30 (0 PM IZI 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.
_ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
D
; i } A CMV is defined as any motor vehicle used to transport passengers or property and. Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I ; i 0 ` ' INDICATE NORTH combination) or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L + Not To Scale -t r r r (example.shuttle or charter bus)-or
• 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
t.-----;-----. 4 1 -f ; } - t transporting employees in the course of their employment(example.employee
-usually a van
vehicle or
ca
03
---- ----4 % ; Hiawatha?Dr i r i 4 transporter sedor des gnated to rransport between 9 agar 15rpassengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O
L____ ____; ; , I 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) XI
CARRIER NAME Z
�r
= ADDRESS D
Cooper?Ave I
0 CITY/STATE/ZIP
cn
. . , r
r , ,
I - MOTOR CARR ID ❑ Interstate El Intrastate
0 Not in Comm./Govt. Not in Comm./Other
' 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 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
73
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 >10; m
m
TRAILER 1 ❑ ❑ ❑ Z
7
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z
White BlackEn
-
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 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