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HomeMy WebLinkAbout2024-00081346 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 00 I00.1 INN �0000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xo0a€82800 u, 9 u21 3 4 1 U, 2 uz 1 U,99 u2 1 U,99 U2 1 1 15 u, 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51,500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202412024-00081346 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n S MCLEAN BLVD Elgin02:24 ® ❑ RELATED ®Y 0 N 12 30 2024 ❑AM ❑YES El NO U1 -< _ _ PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W RT20 EB COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Unknown.0. ! / Unknown Unknown 00-NONE ©1 O , DUE TOCRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10. EN I , 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 4 1<Tl SYSTEM IN ENGAGED 15-OTHER 916.70P 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _.Ii_B Ii,_ 1 0 9 FIRST CONTACT 7_11 : COM VEH 0 ZgJ _5 *II Yes.See Sidebar U1 0 REAR c Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ UNK ❑Y ❑N U2 I' B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same UNK 1 I `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y ❑ N 99 0 m (i..{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv yr 0 y 13-UNDER CARRIAGE 10 2 FIRE 0 ® U2 C c ® F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 916-TOP 3 X ❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *0istrac JDn Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i B i.�.,_4 C.OM VEH ❑ ® U1 CO FIRST CONTACT 1 7 _, _5 •)ryes.See Sidebar C ELGIN IL 60120 0 1 0 EM69690 IL 2025aR Si)0 IL D 0 1 HGCP26898A080570 United Equitable Insuranc ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Mora Enriquez. Mauricio PPQ6008580 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT( (SEAT) (DOB( (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 5 03 / ' D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12/30 l2024 02 24 ®PM in a Work Zone? ®N DIRP co 1 F PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME H . AM If YES check one below: U1 7 C) T O 2 0 2 06 / / ❑PM ❑Construction Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1 - N a, ARREST NAME / / ❑PM ' I ® 0 Utility 1 1 1 0 CITATIONS ISSUED ❑PENDING SLMT 'SSECTION CITATION NO. ROAD CLEARANCE TIME 0 AM F 2 El ARREST NAME 12/30 /2024 02 24 ®PM 0 Unknown work zone type U1 30 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 1526-Walsh.Jacob 602 334-Fries / 0 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 truck trailer -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ® - (example:shuttle or charter bus):or 0 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. ,,.,,,,,,o,,,,,,„,...,,,,,, I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose):or L L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D . ' placarding(example:placards will be displayed on the vehicle). ,Zm 2 t —I CARRIER NAME Z ________ '_ ADDRESS V) 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 Xl Source of above 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 VIM 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ . 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