HomeMy WebLinkAbout2024-00058969 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III (IIIIII II 11111111IllIllHl 10
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555541
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
El NOT ON S
VEHICLE/PROPERTY ®OVER$1.500 El AMENDEDCENE(DESK REPORT) 0 B Injury and JorTow Due To Crash YR 2024I2024-00058969 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I
JAY ST ®gin El
®Y ❑N 09 14 2024 08:O6 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W S LIBERTY
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑arN ❑NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 4 / 1 3 J 2 0 0 3 FOR DAMAGED AREA(S) HtCNT TOWED Ut
NAME(LAST,FIRST,M) , Destinee mo day yr Toyota Corolla 2018 00-NONE 11 .i 0 D1 DUE TO CRASH ® ❑
13-UNDERCARRIAGE FIRE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ® U2 0 m
511 N MCLEAN BLVD F M
❑Y MSYN DUNK VEH. AT CRASH 99-UNKNOWN 916-TOP�3 ,Distraction Value ALGN 2
0
r CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii• 4 COM VEH 0 ® 1 O
F FIRST CONTACT 2 7__. _�5 ^byes,See Sidebar U1 0
Z
2T1 BU RH EXJC975436 State Farm ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Xaypharath,Sengaloune G597314C0913A 1
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o
o RESPONDER 511 N MCLEAN BLVD. ELGIN , IL.60123 (630)333-6259 VEHU 0
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
m / J FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) pY N
s Espinoza Mercado.Olivia 0 9 0 2 1 9 7 8 Chevrolet Traverse 2017 00-NONE Xi
t3-UNDER CARRIAGE O' O DUE TO CRASH 0 2
Q I.
FIRE ❑ [2] U2
v mo day yr 10 II
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 C
DISTRACTED 0 IN SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0
a 386 ECHO LN 2 F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN FI •DistractionValue
to
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR H
p RIST CNT ONTACT 12 7_II 6 I.
CIOMes gee •Sideba❑ ® U1
• C I
Z AURORA IL 60504 B AP75051 IL 2025 0 C)
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)201-0149 E215-6407-8850 IL D 0 1 G N KRG KDXHJ299551 State Farm ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Same J785072C1613 BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
0 RESPONDERY Same U1 =
(UNIT) i SEAT) (0081 (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMSi (HOSPITAL)
2 4 02 /21 /2024 F 14 8 0 1 Aylin Garcia/386 ECHO LN 2,AURORA,IL,60504 Elgin Fire Sherman 996 1
(221)201-0119 - g U2 m
2 6 11 /22/2010 F 2 8 B 1 Kendra Garcia/386 ECHO LN 2.AURORA.IL.60504 Elgin Fire Sherman #occs D
(224)201-0149 _ X
/ ,, U1 1 m
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 1 ComEd pole 432244050 09/14 /2024 08 06 0 AM 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 7
2 ❑ 350 SECOND ST ELGIN IL 60123 2 28
! , PM El Construction *
c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
Q • ARREST NAME Xaypharath, Destinee 3-707 S1507000317 / / ❑PM SLMT
c U , ® 11 1 ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
N AM 30
2 0 ARREST NAME Xaypharath, Destinee 11-901 S1507000316 r / 8 ptil ❑Unknown work zone type Ut
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1507-Ruiz.Alondra 401 - 10 108/2024 01 30 0 PM IZI 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.
F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS
D
; ^ } A CMV is defined as any motor vehicle used to transport passengers or property and. Z
I 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
r { ; a N ; ; combination) or —I
C INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t ; Not To Seale l _i r r r (example.shuttle or charter bus)-or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
t•----;-----% 4 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 , : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example:large van used for specific purpose).or O
L____-:_____; ; ; , a ` Hastings?St _ i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
Ew
.z placarding(example placards will be displayed on the vehicle) 71
{ % =1 CARRIER NAME Z
' ry t ADDRESS 0
N
• CITY/STATE/ZIP 0
r l. ',. ',..
•
MOTOR CARR ID ❑ Interstate El Intrastate
■ •
0 Not in Comm./Govt. ❑ Not inher CommComm/O OO
C
USDOT NO. ILCC NO.
, Source of above Z
If Yes, Name on placard o
4 digit UN NO. 1 digit Hazard class No M
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 g
Did Carrier Safety Regulations(MCS)violation contribute to the crash% A
❑ Yes No ❑ Unknown 0
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 C
Z
Form Number D
m
X1
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
D
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 N
Black Silver
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO:
DUE TO ❑ Redmons/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE