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HomeMy WebLinkAbout2024-00057968 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 1111111 010 III Ifi IIII lull 11111111111 110111011111011 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003566411 u, 9 U21 3 4 1 Ut 3 u2 1 U199 U2 1 Ut 99 U2 1 4 15 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00057968 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg 'r1 E HIGHLAND AVE ® ❑ Elgin RELATED ®Y 0" 09 11 2024 05:12 ®AM ❑YES ®NO U1 .( PRIVATE mo l day/yr ❑PM FLOW CONDITION m FT/MI N E S W DOUGLAS ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL 0 EOUES 0 AIN 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 4 / 0 9 /1 9 7 7 FOR DAMAGED AREA(S) FRONT TOWED Ut Mercedes Bert2220 2011 00-NONE ©' ..0.,D1 DUE TO CRASH ® ❑ - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10-• -. 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 53 U2 2 m 1508 VILLA ST M SYTM❑Y ®SNE❑UNK VEH. O AT CRASH D O 15-99-UUNKNOWN THER9 16-TOP 3 ,Distraction Value g ALGN I r CITY PLATE NO. STATE YEAR POINT OF 8 i. 6 4 COM VEH ❑ ® 1 n F FIRST CONTACT 12 7- ., _5 ^Yves,See Sidebar U1 0 Z WDDGF8BBXBR181493 KEMPER ®Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same 12AU001564753 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER S VEHU L ❑Y ❑ Same" 99 0 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 KW ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 Y N m m 7 / / FOR DAMAGED AREA(S) FROM O TOWED ODCRASH NAME(LAST,FIRST,M) Rojo Cruz,Jesus 0 o day yr 1 9 6 4 General MotorXt� wlpl 2011 oo-NONE 1t' 12 1 fffi 0 2 73 73 v 13-UNDER CARRIAGE 10 1 z FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ ® SPCA C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3O g g X E 243 S ALD I N E ST M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 7. + 6 OS COM VEH Sidebar IN U1 to C H ELGIN IL 60123 0 Q740141 IL 2024 BAR g Z M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (331)442-6091 R226-4206-4211 IL D 0 1GKEK13TXYJ157167 AMERICAN FAMILY ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER I I Same 410474017769 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < REEl Y 0NR Same ut 2 (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)(ITELEPHONE) (EIdSI (HOSPITAL) I I U2 996 1- m / - #OCCS D / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME co DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 11 1 09/1 1 /2024 05 12 ❑pM in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 7 C) T 2 0 24 25 ! r 0 PM El Construction * N 1 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ElAM El Maintenance U2 1 Q ® 11 1 ARREST NAME Munoz, Ruben 3-707 449-372 / / ❑PM< 0 Utility SLMT p U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME N AM 20 T 2 0 ARREST NAME Munoz. Ruben 11-102-A 449-371 r / 8 ptil El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? D Y 30 1516-Mancera. Maria 101 - 10 ,08/2024 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. _ 0 F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I AIO UNS FORMS I _� } A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more thanDDIT 10,000NAL pounds IT(example.truck or truck/trailer -< { combination) or —I r ', ', � � I r NDICATE NORTH 7:1 1 ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } i ', ', i -! ` r r r (example.shuttle or charter bus)-or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----� -t } } } transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or 03 i_____A____: : i , : r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N Unit for direct compensation(example:large van used for specific purpose).or O L____-:_____; i 7 , - i } 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m _p placarding(example placards will be displayed on the vehicle) XI HI A1/6 CARRIER NAME ' I ADDRESS 0i 0 N I •• CITY/STATE/ZIP Hof TO SOW I - MOTOR CARR.ID ❑ Interstate ❑ Intrastate r , r 0 Not in Comm./Govt. Not in Comm./Other , USDOT NO. ILCC NO. C • , XI 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 73 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 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 Tan 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 I Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: DUE TO ❑ Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE