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HomeMy WebLinkAbout2024-00061223 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III Ifi III ll II 11111111111 IIIIIIIIIIIIIIIIIIIIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003566410" u, 1 U2 1 1 1 1 U, 4 U2 1 Ut 1 U2 1 U1 1 U2 1 1 10 Ut 3 U211 *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 SCENEEI NOT ON • 7 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDED (DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061223 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'rI S RANDALL RD Elgin ❑ RELATED ❑Y CON 09 24 2024 01:09 ❑AM El ®No u1 • ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 15 co ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IM N PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EDDES ❑NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 8 / 2 5 /2 0 0 6 FOR DAMAGED AREA(S) FRONT TOWED Ut - mo day yr 2 13-UNDERCARRIAGE t) I 2 FIRE 0 l l SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 l81 U2 O m 1458 N PEMBROKE DR F SYSTEM IN ENGAGED 15-OTHER 9 t6-TOP 3 _ / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN CITY PLATE NO. STATE YEAR POINT OF l COM VEH 0 ® 1 0 7SAYGDED3PF934699 Telsa Insurance ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Gaw, Phillipe TLA-IL-A-9992MJV6 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER oGI RESPONDER y°DEN 3 1458 PEMBROKE DR.South Elgin. IL.60177 VEHU GI 5 ®cRIvER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m m / / FOR DAMAGED AREA(S) FROM TOWED Y N s Rodriguez,Orlando 1 0 0 1 1 9 7 6 Chevrolet Trax 2020 00-NONE ,t' j' , fffi 0 2 —I NAME(LAST,FIRST,M) g mo day yr © ElII Y FIRE ❑ U2 C v t3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 E 213 VILLAGE CREEK DR M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7.1 6 5 Clrve6VSee Sidebar ® U1 C Lake in the Hills IL 60156 0 EF72525 IL 2025 • 0 p 2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)577-4885 R362-6407-6280 IL D 3GNCJKSB7LL233053 Country Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same P010030215 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 1:1RESPONDERY 3 Same u1 _ (UNIT) (SEAT) (DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I - uz 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 El AM Did crash occur El U2 Z N ® 11 1 09/24 /2024 01 09 ®PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM If YES check one below: U1 3 C) T 2 0 28 20 ! / 0 PM ElConstruction * N 3 0 El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z ❑AM ❑Maintenance U2 ® 11 5 ARREST NAME Tadlip. Marytrishaelijah. M. 11-601-Ax 298 001 11 8W / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N BAM 00 T 2 0 ARREST NAME / / ppl Ut ❑Unknown work zone type OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 00 298-Lopez. Mirko 801 275-Engelke , / 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. _ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r_.._r_ __1 1 , 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 i- I I ; i -; ; combination).or —I INDICATE NORTH 7:1 I jEN-1)o por I : BYARROW 2 Is used or designed to transport more than 15 passengers including the driver C1 , 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 i------;-----� i _s -f } - t transporting employees in the course of their employment(example.employee XI transporter-usually a van type vehicle or passenger car).or w Not To Scale ; —1 : i r 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N t for direct compensation(example:large van used for specific purpose).or O L____-L___-1 i , , 11Oi]?3-?Randall?Rd- -: • i ) i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m J ` placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z fm11AlriRtl. 0 ADDRESS N O CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ 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 S ' TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m lJ 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 Gray Gray 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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO ❑ Jims/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE