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HomeMy WebLinkAbout2024-00060277 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III I IIIIIII II II 11111111111111101101111 11110 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003560985 u, 1 U21 3 4 1 U199 1.12 1 Ut 1 U2 1 Ut 1 U2 1 1 10 Ut 1 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 3 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00060277 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'tI 190 E/B EXIT RAMP ®gin ID ®Y ❑N 09 20 2024 07:39 ®AM ❑YES ®NO U1 • ,< PRIVATE mo l day I yr ❑PM FLOW CONDITION m 1 (]� COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR 0 SLOW 15 co ® CJ/MI O E S W N Randall WITH VEHICLES INVLD ❑ STOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' O tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n Subaru WRX 2022 00-NONE FROM FOR DAMAGEDAREA(S) FRO TOWED Ut 0 1 2 / 0 1 J 1 9 9 6 /�DUE NAME(LAST,FIRST,M) . Daniel mo day yr 11-i 1Y 0 ISI 13-UNDERCARRIAGE 10t Y FIRETO CRASH 0 El SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 802 BRANDT DR M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 I PLATE NO. STATE YEAR POINT OF l 6 1._ i_ COM VEH ❑ El 1 0 F FIRST CONTACT __, �_5 'li Yes,See Sidebar Ut Z J F1 VBAF67N9015511 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn Same 2625807SFP13 2 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L • ❑Y ❑N 2 17 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m 1 2 / 1 J 9 1 9 7 M TO FOR DAMAGED AREA(S) FRONT DTO CRASH Y N n NAME(LAST,FIRST,M) Kalas,Ann. K. mo day yr 3 Toyota RAV4 2020 00-NONE ®11: 72 1 ❑ ® 2Xi v 13-UNDER CARRIAGE 6 t j Y FIRE El ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR I 0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X E 2225 DERBY LN F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN II 'OistractIon Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 10 7.'i 6 5 C•IOMeS VEH See Sidebar ® U1 C H Belvidere IL 61008 0 BX30466 IL 2024 RFi 0 f0 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)651-9756 K420-0517-3960 IL D 2T3P1 RFV5LC127301 Country Financial ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Same P12A8116592 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < EE 0R l RESPONDER Same U1 _ (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m / • - #OCCS D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 09/20 /2024 07 39 ❑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 If YES check one below: U1 5 C) T 2 0 1 3 25 28 i / 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 4 ❑AM ❑Maintenance U2 1 ® 11 4 ARREST NAME Cortez Trejo, Daniel 11-306 337000264 / / El PM SLMT o U 0 CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N RAM 50 T 2 0 ARREST NAME / / ppt ❑Unknown work zone type Ut • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID, COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 50 337-Thompson,Charles 901 275-Engelke / / ❑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 r_.._r_ __; ; ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 0D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z r } I I ; i combination).or —I I-"-‘) NDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } 1 , i ~ f C 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 i-- '-- --. , t } transporting employees in the course of theiremployment(example employee Zl No&Toncere_l transporter-usually a van type vehicle or passenger car).or w i____A____: : i , � i i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N z for direct compensation(example:large van used for specific purpose).or O i li c I L____-L____1 1 ; , (�' i i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m / placarding(example placards will be displayed on the vehicle) 71 ! CARRIER NAME .. ADDRESS D ' CITY/STATE/ZIP r , Randall?Road MOTOR CARR ID ❑ Interstate El Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , 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 D TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Orange Blue.Dark - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 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