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HomeMy WebLinkAbout2024-00058948 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi IIIIIII II 1111111111111111111H1 10111111 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003560992' u, 9 uz 1 1 4 1 Ui 2 U2 1 U199 U2 1 U1 99 U2 99 1 12 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE[23 NOT ON 2 VEHICLE/PROPERTY ®OVER$1.500 ❑AMENDED ® B (DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00058948 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 ROUTE 20 ❑Elgin RELATED ❑Y CO" 09 13 2024 07:45 ❑AM ❑YES ®NO U1 .( PRIVATE mo l day/yr ®PM FLOW CONDITION m ^,� � ® 'COUNTY PROPERTY El M N DOORING ❑Y #OF MOTOR CI SLOW 1 U1 02 (]CJ I /MI N E s State St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 D4 ORNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) mo day yr .0. Unknown Unknown DO-NONE 11 12 i' , DUE TO CRASH p 21 ,3-UNDER CARRIAGE 10) 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) SYSTEM IN ENGAGED 15-OTHER DISTRACTED ❑ ® U2 4 m 9 16-TOP 3 r M ❑Y ❑N ❑UNK VEH. AT CRASH POINT OFUNKNOWN 6 il� 4 COM VIER ion�� 0 ® ALGN CITY PLATE NO. STATE YEAR } e 1 F unknown ❑Y ❑N U2 r m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 9 Same unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER SameVEHU X L • 99 GI ❑Y ❑" 5 ®COWER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m 5 1 1 / 0 5 /2 0 0 1 FOR DAMAGED AREA(S) F120 IT TOWED DUE TO RASH Y N n NAME(LAST,FIRST,MI Herrera.Guzman mo day yr Lexus IS250 2007 oo-NONE 1t. 12 , IN 0 273 v 13-UNDER CARRIAGE 10 j Ij 2 FIRE ® 0 U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El 0 SPCA 0 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 9 X a` ® 1710 MARK AVE 1 M ❑Y N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Oistrachon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF 11 ONTACT 1 7_ 6 5 COM VEH ® 0 Ut C co H ELGIN I L 60123 0 EQ61122 IL - a Vee,See Sidebar 0 0 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)629-1154 011533076 OTH Other JTHCK262575014564 American Freedom ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Herrera, Luis 12-243843700 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 1710 MARK AVE 1. ELGIN . IL,60123 (331)308-5711 U1 = (UNIT/ (SEAT) (DOBi ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS(((TELEPHONE I (EMS) (HOSPITAL) n / I U2 996 1— m / - #OCCS D / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ®Y U2 Z N ® 11 9 09/14 /2024 06 06 ®pM in a Work Zone? El DIRP co IN PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: Ut 1 0 T 2 El 20 18 ! / 0 PM ®Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q 1 CO 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 50T 2 0 ARREST NAME I / ptil ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 547-Hometer,William - I / ❑❑PM Workers present? ®N U2 50 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 , Rt?31 _� } 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 I I 1 INDICATE NORTH combination) or —1 O71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. I d i -` ` r r r (example.shuttle or charter bus)-or n X 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 M transporter-usually a van type vehicle or passenger car).or w i_____A____: : i , : i r , 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N fo ect van .or , , Rt?20 i 1 5 r Is anyvehiclecompensation nused to t ansportla nehazardous for material(HAZMAT)specific (HAZMAT))that requires O placarding(example placards will be any on the vehicle) 11 71 T. CARRIER NAME Z ' D ® _ ADDRESS 0N • ® • CITY/STATE/ZIP I O r , : - MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. ElNot in Comm./Other Q USDOT NO. ILCC NO. C , Source of above Z . ❑ Yes 0 No ❑ Unknown A 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 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Blue-Dark - 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE