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HomeMy WebLinkAbout2024-00079438 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I011011000 00 01100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003671FP36 u, 1 u21 1 1 3 u1 4 U2 1 u, 1 u2 1 u, 1 U2 1 5 14 u1 1 u2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 2024I 2024-00079438 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n SOUTH ST Elgin ® ❑ RELATED ❑Y ®N 12 19 202412,— ❑YES El NO U1 -< PRIVATE mo /day/yr 08:08 ®PM FLOW CONDITION m I 0 ®/MI N 0 S W East S Hawthorn Dr COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 6 (A Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 C) 0 5 / Mitsubishi Outlander 2016 00-NONE Q- ©I 7T DUE TO CRASH ® ❑ E 13-UNDER CARRIAGE 10 I 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 02 m M 2 5 SYTM❑Y ®S NE DUNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN - r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F. POINT OF s i�a 4 COM VEH 0 j$J 1 0 FIRST CONTACT 12 7_:—_ __, _5 *Irves.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 M196256 IL 2025 REAR TELEPHONE IL D 0 JA4AP3AU 1 GZ065829 NIA ❑Y ❑N U2 M 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 99 9 Same NIA 3 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y El 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 Ncv 0 Dv CIRCLE NUMBER(S) U1 1 9 y 7 9 Other Other 2014 00-NONE 0. Q!'-O DUE TO CRASH 0 ® 22 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 7 .5 •It Yes.See Sidebar Z ELGIN IL 60124 0 1 0 M196256 IL I C 0 Si) IL B 7 1 HTWDAAN7EH013337 Toirma I Y ❑N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Elgin Township N/A SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH! PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)!(TELEPHONE! (EMS) (HOSPITAL) 1 3 04 / F 2 5 B 1 0 m / / #OCCS > 71 / / UI 2 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 12,19 /2024 08 08 ®PM in a Work Zone? ®N DIRP co I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 0 28 05 12,19 ,2024 09 00 ®PM El Construction >F R 1 3 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ❑AM ❑Maintenance U2 o 1 ® 11 1 ARREST NAME Martinez,Jaime 11-601-Ax S1537-000062 12/19/2024 09 05 Igi PM SLMT igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El AM• El Utility r 2 El ARREST NAME Martinez.Jaime 3-707 S1537-000061 12/19 /2024 08 50 0 PM El Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1537-Mapp.Teddron 702 334-Fries 01 ,07/2024 09 00 ❑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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; 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 truckrtrailer -< INDICATE NORTH p1 N BY ARROW combination):or 2 Is used or designed to transport more than 15 passengers including the driverC - } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L L.___a__._J Uric ma I. } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, — — — _ } for direct compensation(example:large van used for speific purose):or O L L..._a__ i - t i. i I 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires .D . placarding(example:placards will be displayed on the vehicle). XI m -I CARRIER NAME Z ADDRESS 0 T. a«. r, w CITY/STATE/ZIP 00 Not Tb Soot* I MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other �I. ------1 - USDOT NO. ILCC NO. rn XI Source of above Z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Green.Dark u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE