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2024-00059298
ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II 111111llIllIllHllfll 1101011 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003555523 u, 1 U21 1 1 1 UI 7 U2 1 U, 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 El$501-$1.500 ®ON SCENE • 3 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1,500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059298 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 LILLIANm ST ❑ Elgin RELATED ❑Y coN 09 16 2024 10'33 ®AM ❑YES ®NO u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ®SLOW 1 U) 050 0/MI N 0 S W MCLEAN ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N [] FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EDDES ❑NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 (7 0 9 / 2 0 /1 9 9 6 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) MUNIZ,JUAN, M. mo day yr Dodge Ram 2500(van) 2017 0-NONE 11 1s , DUE TO CRASH 021 13-UNDER CARRIAGE 10 1• ,; 2 FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 4 m 465 FREMONT ST M SYTM THER ❑Y ®SNE❑UNK VEH. O ATCRASH D O 99-U 15-UNKNOWN 1 9 76-TOP 3-4 Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 FIRST CONTACT 12 7 � 6 1 COM VEH 0 El5 "if Yes,See Sidebar U1 1 0 jL __. �_ Z 3C6TRVDG3HE5443 STATE FARM ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a VALDIVA-JUAN 0125079SFP13 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER 40W64 PLANK RD VEHU L ❑Y ❑N 98 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N a NAME(LAST,FIRST,M) GRONKE_ KATHERINE, M. mo 08 day yr 1 98 7 Nissan Altima 2013 00-NONE +c) 12 s REoCRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ IN SPOR 0 a 215 N COMMONWEALTH AVE F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y El N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 11 6 ii/.4 COM VEH ❑ ® U1to F, FIRST CONTACT 6 7- .{ -i)•If Yee,See Sidebar C E LG I N IL 60123 0 Z774764 IL 2025 REAR 0 (/j, M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)849-8240 G652-5138-7831 IL D 0 1N4AL3AP5DC124591 STATE FARM ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I HENRY. KATHERINE, M. 0537013SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y 9NR 215 N COMMONWEALTH AVE. ELGIN . IL-60123 U1 = (UNIT( (SEAT) ;DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)l(TELEPHONE( EMS) (HOSPITAL) n I I U2 996 r m #OCCS D 73 / /• 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 1 ® 11 1 09/16 /2024 10 33 ❑pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 3 C) T 2 El 03 99 ! l 0 PM ElConstruction a c' 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 CO 11 1 ARREST NAME BRISENO MUNIZ.JUAN. M. 11-601 244-1769 / / ❑PM SLMT o U ®CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility I 2 0 ARREST NAME BRISENO MUNIZ-JUAN, M. 6-101 244-1770 r / Bptil ❑Unknown work zone type Ut 30 2 2 3 ❑ • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 244-Blomberg. Michael 701 272-Bajak 10 r 22/2024 01 30 ®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. r 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. Z r- -r--- 4 , 4 r r r r r , , , , . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or 'I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! i ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------'-----• + + • : - -, 1 1 1 i } - i• transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or 03 ' i r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O 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 . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP O , , . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r•---, r - DO ILCC NO. m U N XI , Source of above 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? ID Yes No ❑ Unknown 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 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 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 White Black - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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