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HomeMy WebLinkAbout2024-00061432 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III Ifi IIIIIII II 11111111111 110110 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003565169" u, 1 U2 1 3 4 1 U1 1 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.5000 NOT ON S®ON SCENE • 14 VEHICLE/PROPERTY Ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00061432 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'TI N STATE ST ®gin ❑ RELATED ❑Y coN 09 25 2024 02:00 ❑AM El ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m ®25 ®I MI OE S W TOLLGATE ) PEDALCYCUST El ® FREE FLOW # LNS O tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 05 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Ford Explorer 1 9 8 92004 00-NONE 1 DUE TO CRASH 0 21 NAME(LAST,FIRST,M) .A. mo 0 3 / day J yr P 11- 12 13-UNDER CARRIAGE 10 1 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 05 m SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 2500 WATERMARK TER 101 M ❑Y ®N DUNK VEH. 0 ATCRASH 0 99-UNKNOWN Distraction Value 9 ALGN I r CITY PLATE NO. STATE YEAR POINT OF ®ii 6 `O COM VEH 0 El 1 n F FIRST CONTACT 5 O7-:I ]-OS 'Yves,See Sidebar U1 0 Z 1 FMZU73K44ZA09363 INSURE ON THE SPOT ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same ILT5525044 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > '' RESPONDER Same VEHU L ❑Y ®N 2 G1 ' ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED s GAYTAN- KAYLA 0 9 2 9 2 0 0 3 Toyota Tacoma 2010 00-NONE O j O ❑ ® 2 Xi NAME(LAST,FIRST,M) mo day yr 9 Oi! 2 FIRE ❑ MI U2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 ® SPOR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a 328 WHEELOCK ST F ❑Y Igl N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POEH FIRST CNT OONTACT 12 7. . 6 ` .5 •CIrOVeeM VSee Sidebar ® U1 to H ELGIN IL 60123 0 2909979E IL 2024 REAR 0 C/1 D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)387-8020 G350-5000-3877 IL D 3TMLU4EN7AM050180 AMERICAN FAMILY ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 GAYTAN. MILTON 410711420866 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 328 WHEELOCK ST. ELGIN . IL•60123 (224)587-2426 U1 = (UNIT( (SEAT) ;DOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 1— m - '#OCCS > /• / U1 1 m I I 1 0 Ev MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 09/25 /2024 02 17 ®pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 a 2 ❑ 2 28 / / 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ARREST NAME Graves.Zachary.A. 11-901 1506-279 / / El Pm SLMT ® 1 1 1 •' 0 Utility p U 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N II AM 45 2 ❑ ARREST NAME , / ptil ❑Unknown work zone type Ut 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1506-Nunez. Maria 501 334-Fries 11 , 12/2024 09 00 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. _ 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 1 i ; i INDICATE NORTH combination) or 57 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ', ', i -! ` r r r (example'.shuttle or charter bus)-or 0 501 i [ Nor To SoW ; • j 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 <-----`-----: ' 9 9 P by } } } transporting employees in the course of their employment(example employee 71 L transporter-usually a van type vehicle or passenger car).or w �____A____: : , — — — —- _� : i r i 4 Is used or designated to transport between 9and 15 passengers,including the driver, N ect sation( xample. van used r. i } i 5 r Is'rany vehicle usedtotransportla nehazardous for matenalspecific (HAZMAT))that requires O \ rn placarding(example placards will be any on the vehicle) 71 — — — — CARRIER NAME Z . ' uroTATSWT Ii. ADDRESS 0 N '• CITY/STATE/ZIP 0 , , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. • , 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 5 Z Form Number 0 _ m — xi IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m CA LOCAL USE ONLY TRAILER VIN 2 m 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 Silver Brown - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE XI 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 ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE