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HomeMy WebLinkAbout2024-00059627 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi I III III II 11111111IllIllHl 101 11111 1111 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003555532' u, 9 uz 1 1 1 1 u,16 u2 1 U199 U2 1 U1 99 U2 1 1 9 u1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$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 SCENE0 NOT ON 1 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDED (DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00059627 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 N GIFFORD ST ❑Elgin RELATED ❑Y co" 09 17 2024 04:05 ❑AM ❑YES ®NO U1 .< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W NORTH ST 'COUNTY PROPERTY El Y M N DOORING ❑y #OF MOTOR ID SLOW 1 N ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0 DI DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EOUES 0 NW 0 Rey ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FROM TOWED U, O NAME(LAST,FIRST,M) ,O. mo / day / yr Unknown Unknown DO-NONE 11 llJJ O /1DUETOCRASH ❑ ,3-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� OO SYSTEM IN ENGAGED 15-OTHER 9 16-TOP®DISTRACTED 0 l U2 2 m ion r ❑Y ❑N ❑UNK VEH. AT CRASH POINT KNOOF 8 O COM VIEH Value ❑ ® ALGN CITY PLATE NO. STATE YEAR 6 1 F ID VIN INSURANCE CO. EXPIRED 1 ° NIA ❑Y ❑N U2 LI I— m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Ya r Same NIA 1 I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER S VEHU X L ❑Y ® Same" 99 0 m 0 DRIVER ® PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NMV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N —I s Toyota Camry 2021 00-NONE 1 ' 1 DUE TO CRASH ❑ ® 2 , NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE i 12 I:_2 FIRE ❑ ® U2 C v STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED0 a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN © 4 •Distraction Value g U1 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF COM VEH 0 ® C FIRST CONTACT 5 0..I 6 '__.5 •If Yes,See Sidebar EN96971 IL 2025 P O I;p M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T1 G 1 1 AK7M U587602 Direct Auto ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Gutierrez Gonzalez.John.A. PAIL001215382 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 137 N GIFFORD ST 2. ELGIN . IL,60120 (224)856-0531 Ut = (UNIT) i SEAT) (DOB) (SEX) ISAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME')I ADDRESS i(ITELEPHONE) (EMS) (HOSPITAL) Clemente Aranda Castillo/150 N GIFFORD ST ,ELGIN.IL.60120/ 996 1- W 09 /1 3/1975 M (224)339 o7sz_ U2 m / / • #OcCS y / / lit 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 18 1 09/17 /2024 04 05 ®pm in a Work Zone? El DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: Ut 5 C) T 2 ❑ 28 99 ! / 0 PM El Construction * N t 3 o 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM El Maintenance U2 7 Q 1 ® 11 1 ARREST NAME / / ❑PM 0 Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N B AM 30 2 0 ARREST NAME r / ppl ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El 30 1532-Hernandez, Daniel 301 334-Fries , / El 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 ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I i combination) or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. J. 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 i_-----.-----• + + {�_ i } } transporting employees in the course of their employment(example employee � 2 \ transporter-usually a van type vehicle or passenger car).or w �____A____: : ; ` q : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u) I ) ) ) for direct compensation(example:large van used for specific purpose).or O L____"-____; 4 i } 1 5 Is any vehicle used totransport an hazardous material(HAZMAT)that requires m r placarding example-placards will be displayed on the vehicle) 71 2. CARRIER NAME Z ' N .. ADDRESS 0 • CITY/STATE/ZIP r. Not To Scale , _ MOTOR CARR ID ❑ Interstate ❑ Intrastate G) 0 Not in Comm./Govt. El Not in Comm./Other 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White - 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE