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HomeMy WebLinkAbout2024-00059403 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III Olfi Ifi 1Ill111 11111111 11111 11111111111 111111111 Ill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL •MANY n03560963 u, 1 U21 3 4 1 U1 7 U2 1 U, 1 U2 1 U1 99 U2 99 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 1 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059403 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 '�'I W/B RT20 ®gin El ®Y ❑N 09 16 2024 06:24 ❑AM ❑YES ®No u1 -< PRIVATE mo l day I yr ®PM FLOW CONDITION m 1 O(]� 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR El SLOW 1 U) ® �CJI MI N E CI W McLean Blvd 'WITH VEHICLES INVLD El STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑SIN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / 0 7 /2 0 0 1 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mo day yr Ford Ranger 1999 00-NONE 11 12 DUE TO CRASH 0❑ 13-UNDER CARRIAGE FIRE 102 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ISI 0 U2 m 1450 LARKIN AVE 5 M ❑Y ESYlM El LINK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH ❑ ® 4 O ~ 1 FTYR14VXXPB63342 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same K508227F2813 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L El Y ®N 2 t7 57 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Lazara Canuto. Emiliano mo day yr 0 8 0 8 1 9 6 7 Honda Element 2008 00-NONE 1c 12 '_s Re o CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE I I c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 4 X a` 973 STEPHEN AVE M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j all! 4 COM VEH ❑ ® U1 to I— FIRST CONTACT 7 4 5 •IfYes,See Sidebar ELGIN IL 60123 0 EV12766 IL 2024 kArt 4 Cl)C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)645-2591 L262-2006-1967 IL D 0 5J6YH18968L015398 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 3357104SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 POND ON Same U1 = (UNIT) I SEAT) (DOBi )SEX! ;SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 06 /29/2005 M 2 4 0 1 0 Juan Munoz/1450 LARKIN AVE 5,ELGIN-IL-60123 Refused 996 (630)641-6536 - U2 m / / #OCCS y / /• • • ut2 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 ® 1 1 1 09/16 /2024 06 24 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 7 C) T 2 ❑ 28 10 ! I 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance uz Q 1 ® 11 1 ARREST NAME Munoz,Shteven 11-601-Ax 1525000307 / / ❑PM SLMT o UCITATIONS ISSUED PENDING • ROAD CLEARANCE TIME 0 Utility o N 0 ❑ SECTION CITATION NO. AM 35 2 0 ARREST NAME 09/16 12024 8 PM ❑Unknown work zone type Ut T 2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1525-Nava,Oscar 701 334-Fries 10 /22/2024 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 0 -� } A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 I i combination) or —I Not TO.Scale INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. I d iI. ` 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 t.----.....---% 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 i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____-:_____; i ; , -t i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) XI SB CARRIER NAME '' ADDRESS 0 r,: Rt720?exdt?mmp (n '• en • I • • CITY/STATE/ZIP • MOTOR CARR ID ❑ Interstate ❑ Intrastate ~ O - _ _ ❑ Not in Comm./Govt. ElNot in Comm./Other O USDOT NO. ILCC NO. C , Source of above Z . own tank)? ❑ Yes ❑ No ❑ Unknowr 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 Cr 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 En Black Brown - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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