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HomeMy WebLinkAbout2024-00061342 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III IIII IIIIIII II 11111111111 110111011111111111101I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003566406 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 U1 1 U2 3 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 EI NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061342 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 LAWRENCE AVE ❑Elgin RELATED ®Y ❑N 09 25 2024 07:52 ®AM ❑YES ®No u1 ,< PRIVATE mo l day I yr ❑PM FLOW CONDITION m FT/MI N E S W WING PARK ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 0 0 8 / 1 3 /2 0 0 3 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) SEGOVIANO, ESMERALDA, M. mo day yr Jeep(after 198fgriot 2007 0-NONE �� 12i' , DUE TO CRASH p 21 13-UNDER CARRIAGE 1U I 2 FIRE ❑ 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 99 m 469 FREMONT ST F ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 iI 6 ii-4 •COM VEH ❑ El 1 0 A 1J8FF48W87D393380 FALCON INSURANCE CO. ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a SEGOVIANO. ROSA 01001219885 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER 517 MILL ST, ELGIN , IL.60123 VEHU L ❑Y ❑N 2 G0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NOV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) WILSON, DEVONTE, L. mo 0 6 day 1 9 9 3 Dodge Durango 2021 oo-NONE 11 12 ' s FIREETocRasH ❑❑ ® U2 2 C I', yr 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 ® SPOR C) a` 847 S RANDALL RD 154 M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 0 X ❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR I8T CNT OONTACT 3 TF _11 6 1_5 C•IOMe6 3eeSidebarH ❑ ® U1 to H ELGIN IL 60123 0 AT25736 IL 2025 MAR 0 CCn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (708)979-1882 W425-1729-3178 IL B 7 1C4RDJDG7MC695171 GEICO ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I WILLIAMS.SATEN,J. 6141522059 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER PO0NR 1287 FLEETWOOD DR 104. ELGIN - IL,60123 (331)588-1553 U1 = (UNIT) I SEAT) (DOBi (SEX) i ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS ft WITNESS ONLY (NAME)i fADDRESS)U(TELEPHONE I (EMSi (HOSPITAL) 1 6 07 /30/1976 F 2 4 0 1 0 ROSA SEGOVIANO/517 MILL ST,ELGIN,IL,60123 996 r (630)440-0880 U2 m W 03 /01 /1986 M VICTOR Manuel RIVERA/ 265 FRANKLIN ,ELGIN,IL.60120/ #OCCS D (224)401-2265 _ X / / u1 2 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 4 91 ,51 /024 07 52 ❑pM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 3 2 ❑ 2 99 ! , ❑PM ❑Construction * N T 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 6 Q 1 El 11 4 ARREST NAME GALVAN SEGOVIANO, ESMERALDA, M. 11-904-B w244-1775 / / ❑PM SLMT o u 0 CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME (D Utility o N B AM 30 2 0 ARREST NAME 1 I ptil ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME El Y 30 244-Blomberg, Michael 701 275-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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS passengers or property' } A CMV is defined as any motor vehicle used to transport and. Z r-"--r----, , 1 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r 1- i ; i r r , , i combination).or —I INDICATE NORTH 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', .1 ! i L ' ' '. ', ' I ` r r r (example'.shuttle or charter bus)-or n S ; ; I • I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----'-----• • + + • : - -, 1 1 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or CO ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME 2 ' .. ADDRESS 0 N • CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate . . ❑ Not m Comm./Govt. ❑ Not in Comm./Other Q C ---- ----, r r r r r•---, r - DO ILCC NO. m U N XI , Source of above z • . ❑ Yes ❑ No ❑ Unknown g Did Carrier Safety Regulations MCS)violation contribute to the crash? ID Yes No ❑ Unknown 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 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 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. y White Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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