Loading...
HomeMy WebLinkAbout2024-00057204 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III I IIIIIII II 11111111111111111110111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003553541 u, 1 U21 3 4 1 Ut 4 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 10 Ut 1 U2 3 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LEI No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00057204 VENT * ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 BOWES RD ® ❑ Elgin RELATED ❑Y coN 09 08 2024 12:17 DP", ❑YES ®NO U1 PRIVATE mo /day I yr ®PM FLOW CONDITION m q COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 15 co IX!- 0/MI N 0 S W Randall Rd 'WITH VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS ' 0 I&ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NNv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut O , H. 0 3 / 2 6 J 1 9 6 1 Ford Explorer 2015 00-NONE 11 1 DUE TO CRASH p 21 -NAME(LAST,FIRST,M) g mo day yr 12 E 13-UNDERCARRIAGE FIRE 0 IA 7 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 1l U2 m 1061 AVERILL DR M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP® I ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF 8 6 O COM VEH 0 ® 1 O F 1FM5K8F88FGB71974 Farmers Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR aSame 191234621 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER❑ ❑N3 Same VEHU X GI 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EOUES 0 KW ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Enriquez- Roberto,G. 0 6 0 9 1 9 5 0 Chevrolet Trail Blazer 2004 00-NONE 1t r 1$ 1 0 ® 2 -I v mo day yr 13-UNDER CARRIAGE 10 j I: 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 3 a 550 MARGUERITE ST M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 7 O II a II S COM VEH 0 ® U1 al If Yes,See Sidebar ELGIN IL 60123 0 7787598 IL 2024 I 0 (/j, D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)695-7017 E562-7275-0164 IL C 1 G N DS 135042446469 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 1138937SFP7017 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER El 3 Same Ut _ (UNIT) i SEAT) iDOB) (SEX) )SAFT) (AIR) IINJI (EJCT1 (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) EMS) (HOSPITAL) 2 3 01 /1 4/1950 F 2 3 0 1 0 Rita A. Enriquez/550 MARGARITE ST.Elgin.IL.60123 U2 996 r (847)695-7017 , m / / #OCCS D / / ut1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z N ® 11 1 09/08 /2024 12 17 ®PM in a Work Zone? ®N DIRP D 1 1 PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM If YES check one below: U1 7 T 2 ❑ 28 20 ! / 0 PM El Construction * r��A 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Ferro,Angelo, H. 11-601-Ax 298001109 / / El PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N 8 AM 45 1 T 2 0 ARREST NAME 1 / pti1 0 Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 298-Lopez, Mirko 702 272-Bajak , / p PM ®N U2 I 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 ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i 1 INDICATE NORTH combination) or XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. ', i -` ` r r r (example.shuttle or charter bus)-or 0 S R'ndi7Rd. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----.....---% i -i } - i transporting employees in the course of their employment(example.employee ,3 -usually a van vehicle or A . .l. , I I I , i r i 4a Is usedror designated to trransport between 9 andgr 15rpassengers,including the driver, C for direct compensation(example:large van used for specific purpose).or O L____�____; , i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires I I _N placarding(example placards will be isplayed on the vehicle) 13 rn 1 L. I_ I Not To Scale I CARRIER NAME Z . • I �i i ADDRESS D _ P4A (n I ` I CITY/STATE/ZIP 0 • MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Red Gold - 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 DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE