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HomeMy WebLinkAbout2024-00058732 , l Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii Ill DIII III 1001lu ll 111111111111111011011111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035609157' u, 1 U21 1 1 1 U, 2 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.5000 NOT ON S ®ON SCENE 2 VEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash YR 2024I2024-00058732 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 DUNDEE AVE ❑ Elgin RELATED ❑Y coN 09 13 2024 05:06 ❑AM ® ❑YES NO ut ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑'' #OF MOTOR ❑SLOW 1 N EP ®/MI N E OS W Franklin Blvd 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EOUES ❑NMV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 6 / 0 2 /2 0 0 6 FOR DAMAGED AREA(S) FRONT TOWED U, 13-UNDER CARRIAGE ��I• I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 4 m 539 STELLA CT M THER ❑Y ®SYSNEM IN❑UNK VEH. n AT CRASH ENGAGED 0 99-UNKNOWN 9 76-TOP 3 .Distraction Value ALGN 2 T. CITY PLATE NO. STATE YEAR POINT OF 8 1� 6 1 4 COM VEH ❑ ® 1 0 a ~ 2C3KA63H36H395648 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Bucio,Carla. M. 12RA000020478 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r L RESPONDER E 539 STELLA CT. ELGIN , IL.60120 (224)508-3514 VEHU 73 GI s ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m m / / FOR DAMAGED AREA(S) ft2o IT TOWED Y N NAME(LAST,FIRST,M) Kendall.Anthony,w. 0 mo8 day yr 1 9 6 6 Ford Escape 2008 00-NONE 1G) 12 I FIRE0 DUE o CRASH O ® U2 2 C I', 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR t') SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X E. 562 AN N ST M ❑Y Igl N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF NTACT 1 7_'1 a 1_8 C•IOMesVEH See Sidebar ® U1 to C H ELGIN IL 60120 0 CE84028 IL 2025 I0 ((I M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 224558 K534-0196-6231 IL D 0 1FMCU92Z88KA44132 KEMPER ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 12AU001135724 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDERY Same Ut = (UNIT) I SEAT) i DOB) ISEX' ;SAFT) (AIR) iINJI (EJCTI (EPTH) PASSENGERS Si WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 01 /1 7/2005 M 2 4 0 1 0 Christian m. Fierros/317 ANN ST.ELGIN.IL.60120 - 996 r (224)704-6058 , U2 m 2 4 11 /27/1987 M 2 4 0 1 0 Kenneth A. Denk/811 LOGAN AVE.Elgin-IL-60120 #OCCS D (224)465-4026 _ 73 2 3 05 /25/1969 F 2 4 0 1 0 Lisa R. Denk/809 LOGAN AVE-Elgin,IL,60120 Ut 2 m (847)769-4205 D 2 6 09 /1 6/1985 M 2 4 0 1 0 Garrett R. Nibbler/201 HEINE AVE.ELGIN-IL.60123 0 (224)558-3752 U2 4 2 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y N i ® 11 1 09/13 /2024 05 06 0 pm in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 2 a 2 ❑ 2 28 ! / ❑PM ❑Construction * N 3 ❑ izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance uz Q CO 11 1 ARREST NAME Camargo. Daniel 11-906 1518000306 / / ❑PM SLMT o U ❑CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility o N B AM 30 2 0 ARREST NAME / / ptil ❑Unknown work zone type Ut 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1518-Versetto. Elisa 102 334-Fries 10 / 15/2024 09 00 p 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. 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 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer , r 1 ; I combination)or —I INDICATE NORTH XI • BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I d i f I -t ` r r r (3e.xample.shuttle or charter bus)-or Is designed to carry 15 or fewer passengers and operated a contract carrier 0 t------;-----. i — -f } - i- transporting employees in the course of their employment(example.employee M —gym, §_ transporter-usually a van type vehicle or passenger car) or 03 i . i i- . 4 Is used or designated to transport between 9 and 15 passengers,including the driver, Ifor direct compensation(example large van used for specific purpose).or O L____ ____; 4 ; , I i ) 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 PJ I. CARRIER NAME ' t ADDRESS 0 22. C) CITY/STATE/ZIP r i Not To Scale I MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. m XI , Source of above Z . —I Were HAZMAT placards on vehicle'? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No PJ 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Red RedEn - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 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