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HomeMy WebLinkAbout2024-00081329 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0011111 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a67640 u, 1 U21 3 4 1 U1 3 U2 1 U, 1 1_12 1 u1 1 U2 1 1 15 u, 1 u2 1 *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 El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 2024I 2024-00081329 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l ® ❑ RELATED ®Y 0 N 12 30 2024 ❑AM ❑YES N NO U1 SUMMIT ST Elgin01:19 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W HIAWATHA DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 -I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 eaves 0 Nuv 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q 0 / !1 9 NAME(LAST,FIRST,M) FERNANDEZ BARRIOS. KEN DY mD 9 1 Honda Pilot 2009 00-NONE „_, Qzftf,a:/DUE TOCRASH ❑ VI E 13-UNDER CARRIAGE i : 2 FIRE 0 N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 <T1< �0 F 2 4 El ONE❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UUNKNOWN 9 16-TOP 3 `Distraction Value 9 ALGN = 1• CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i�6 �i COM VEH 0 Ea 1 0 ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1 ZCK85945 IL 2025 REAR TELEPHONE IL D 0 5FNYF48478B025685 KEMPER IV ELGIN ❑Y ®N U2 r'I R 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 1 99 9 Same 12RA000032673 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 9 2 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 NCv ❑Dv !1 yr 9 6 0 Hyundai Tucson 2022 00-NONE OI t2 c, 2 DUE O CRASH rg D U2 2 C Ti ©-UNDER CARRIAGE F 2 4 SYSTEM IN 1 ENGAGED 1 15-OTHER 9.16-TOP 3 X ®Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:, COM VEH ❑ N U1 CO FIRST CONTACT 11 7� _5 •(ryes.See Sidebar H ELGIN Z IL 60120 0 1 0 CY45643 IL 2025 I 0 Si) M IL D 0 5N MJ BCAE8N H034737 ALLSTATE ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 1 99 9 Same 881 876 779 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused 0 YD®N 9 u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 12,30 /2024 01 19 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 25 28 , , 0 PM El Construction >E R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -a, ARREST NAME FERNANDEZ BARRIOS. KENDY 11-305-A 374001287 / ! ❑PM SLMT r N 1 ® 11 4 0 Utility SECTION CITATION NO. ROAD CLEARANCE TIME Ely CITATIONS ISSUED PENDING t 2 El ARREST NAME 12130 /2024 01 48 ®PM El Unknown work zone type U1 40 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 40 374-Rizzu-o. Michael 201 275-Engelke 21 r 12 ,25 01 30 ®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 rnww.nuzort 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer `----'-----; ) INDICATE ARROW ENORTH combination):or .Z-1 BY2 Is used or designed to transport more than 15 passengers including the driver Not To Scale (example:shuttle or charter bus):or C I I ~ ' 3. Isdesigned tocarry 15 or fewer passengers and operated a contract carrier O pe 9 pe by - ------;----; ,j ' ` - transporting employees in the course of their employment(example:employee X } r } transporter-usually a van type vehicle or passenger car)or CO L L.___a._ - - - I OMIT,—I — — - } 1} 4. Is used or designated to transport between 9 and 1passengers,includingthedriver, for direct compensation(example:large van used fors specific purose):or O _ i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires AIM J n j placarding(example:placards will be isplayed on the vehicle). — — — ( Z ff CARRIER NAME Z auMMn497AEEr - ._ ADDRESS 01 1 � n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A 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 cn LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver White 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 DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE