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HomeMy WebLinkAbout2024-00079097 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 01101100 1101000100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xc036:2a15 u, 2 U2 3 4 3 U116 u2 U, 1 U2 U, 1 U2 5 6 U1 3 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202412024-00079097 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1 HIAWATHA DR El In03:06 ® ❑ RELATED ®Y 0 N 12 18 2024 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m FT!MI N E S W SUMMIT ST COUNTY PROPERTY :IY ® N DOORING ElY #OF MOTOR 0 SLOW Cl) ❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 O 6 ! 13-UNDER CARRIAGE 10 r I! 2 FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m M 2 4 SYSTM❑Y IN NE DUNK VEH. 0 AT CRASH 99-UUNKNOWN THER9©TOP 3 `Distraction Value ALGN - r 0 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,:it s �i 4__s *u Yea.See Sidebar u1 COM VEH 0 j$J 1 0 ZFIRST CONTACT 11 T_ELGIN IL 60123 0 1 0 EJ82989 IL TELEPHONE IL 0 1 C4NJRBB1 FD190169 State Farm ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same 0985697-SFP-13 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 ❑ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑N4v ❑Ncv ❑Dv yr 12 _ X1 o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac) n value U1 3 - POINT OF 8 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T' —d:=5 •COMI sVSee •Sidebar❑ 0 C ED F` pEAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 120 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 29 3 City of Elgin small street light 12,18 l2024 03 06 ®❑pM AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v 1 2 ❑ 150 DEXTER ST Elgin IL 60120 19 15 ! ! ❑PM ❑Construction Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 -a, ARREST NAME Aguilar Ugarte, Francisco,J. 11-601 752499 ! ! 0 PM SLMT o U1 0 igI CITATIONS ISSUED ❑PENDINGUtility u SECTION CITATION NO. ROADCLEARANCE TIME AM ❑ t 2 ❑ ARREST NAME Aguilar Ugarte, Francisco,J. 11-708 752500 12!18 /2024 03 51 [�PM ❑Unknown work zone type U1 35 n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 469-Taylor,Jonathan 202 11 , 31 /025 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 -< c r 1 K `� aummrPetrwr 1 f INDICATE NORTH combination):or p3 _ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver -I } I I Nof lb �J - } (example:shuttle or charter bus):or 0 1 I I 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 I I transporter-usually a van type vehicle or passenger car):or w __ __ �°,✓ I I _ 4. Is used or designated to transport between 9 and 15 passengers,including rCjt I. } I. g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O L I------;-----I MI x�= �HI•wit40 - I. } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI —1 - CARRIER NAME Z ADDRESS I I CITY/STATE/ZIP 0 I � t Ito - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate 1 1 r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --4. - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI XI 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 ❑ 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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE