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HomeMy WebLinkAbout2024-00059267 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III I IIIIIII II 111111llIllIllHllfll I101011IllIl II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003555522- u, 1 U21 1 1 1 U199 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 0 NOT ON VEHICLE/PROPERTY Ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059267 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 RT20 WB ❑Elgin RELATED ❑Y coN 09 16 2024 07A9 ®AM ❑YES ®NO U1 • ,-< PRIVATE mo l day I yr El PM FLOW CONDITION m qQ(y� ® 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR 0 SLOW 15 co IIXXII__ ��CCJJ/MI N E s RT25 Exit 'WITH VEHICLES INVLD El STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' O tg DRIVER 0 PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGED AREA(S) FRCNT TOWED Ut 0 NAME(LAST,FIRST,M) , Graciela Ford Taurus 2010 00-NONE /�mo / day J yr 0 © O DUETOCRASH ❑ 21 3 13-UNDERCARRIAGE tpi z FIRE ❑ ICI < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 m 22 S OLTENDORF RD F SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 I PLATE NO. STATE YEAR POINT OF j 6 • COM VEH 0 ® 1 0 0 r' 1 FAH P2EW2AG 107072 Progressive ❑Y ®N U2 21 . m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR aSame 966924137 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑N 2 GI 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 NOV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m FOR DAMAGED AREA(S) )IT TOWED NAME(LAST,FIRST,M) s Janiec.Ava.G. 0 5 / 3 0 J 2 0 0 8 Honda CRV 2011 00-NONE t3-UNDERCARRIAGE 1t' �' DUE TO CRASH ❑ ® 2 XI ©,11 FIRE ❑ El U2 ✓ mo day yr C c t9 IN ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) Y DISTRACTED 0 SPDR SYSTEM IN ENGAGED 15-OTHER 9 '16-TOP 3 0 E. 284 ASPEN CI F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N 8. ) Ii 4 COM VEH 0 IN U1 ap CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST OF 6 a ®•IfYes,See Sidebar C Z Gilberts IL 60136 0 2443745 IL 2025 _ O fp D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)379-6324 J520-0070-8754 IL D JHLRE4H7XBC003963 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Cooley.George,J. 1751065-SFP-13 BAC ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 271 S HICKORY AVE. BARTLETT. IL.60103 U1 = (UNIT) 'SEAT) ;DOB' (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME'/(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 4 3 03 /09/1971 M 2 3 0 1 Ernest Cano/850 LAKESIDE DR.BARTLETT.IL.60103 U2 996 r (224)550-9151 _ m / / #OCCS y / / U1 1 m / 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 1 09/16 ,2024 07 49 ❑pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 0 T 2 0 28 99 • ! / 0 PM ❑Construction * c' 3 ❑ izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑ ❑AM Maintenance uz 7 Q CO 11 1 ARREST NAME Gamboa,Graciela 11-601 414-959 / / ❑PM ' o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility SLMT 'd NIIAM 55 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut T 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 55 414-Lara. Raul 401 404-Duffy 10 / 15/2024 09 00 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 . D r_.._r_ __ ; ; A CMV is defined as any motor vehicle used to transport passengers or property and. 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z I I ; i -; ; combination).or INDICATE NORTH 711 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', d i -` ` r r r (example.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 .1-- -1-- -- 4 1 -i } - i- transporting employees in the course of their employment(example.employee 71 transporter-usually a van type vehicle or passenger car).or w i____A____: : i : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N 'Owl bDIE. I for direct compensation(example:large van used for specific purpose).or O i_____t-____; . , t i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires _ placarding(example placards will be displayed on the vehicle) 71 M CARRIER NAME Z ' ADDRESS N ' O CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. Not in Comm./Other , USDOT NO. ILCC NO. , Source of above Z . IDOT PERMIT NO WIDELOAD? ❑Yes ❑No = ' TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver 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