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HomeMy WebLinkAbout2024-00061705 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 OIl III II 0 lull 11111111111111111111111111� III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035;2237 u, 1 U21 3 4 1 UI 7 U2 1 U, 1 U2 1 u1 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00061705 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 DUNDEE AVE ❑Elgin RELATED ❑Y CON 09 26 2024 04_28 ❑AM ❑YES ®NO U1 ,•< PRIVATE mo l day I yr ®PM FLOW CONDITION m FT/MI N E S W STEWART ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 0 5 / 2 9 /1 9 7 6 FOR DAMAGED AREA(S) HtCNa TOWED U1 Buick Regal 2012 00-NONE Q 1 O 0 DUE TO CRASH El - E NAME(LAST,FIRST,M) VILLA. Rene.O. mo day yr 13-UNDERCARRIAGE FIRE ElSTREET SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED El U2 4 m 1338 NORTH AVE M SYSTM THER ❑Y El NE UNK VEH. 0 ATCRASH 99-UUNKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = W. CITY PLATE NO. STATE YEAR POINT OF 8 i1 6 i+• 4 COM VEH ❑ ® 1 O F FIRST CONTACT 12 7_ _{_�5 ^Yves,See Sidebar U1 0 Z 2G4GT5GV6C9157803 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 23323300SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 G) 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 NOV ❑soy 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) RONQUILLO-HERNANDEZ_SAUL 0 o 0 d7ay 1 9 y 8 Ford Explorer 2008 00-NONE �o) 12 Z REocRASH p❑ ® Uz 2 C c 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPOR C) SYSTEM IN 0 ENGAGED 9 15-OTHER 9 16-TOP 3 9 0 X ❑Y MIEl113 BOLZ RD M N UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 i 4 COM VEH ❑ ® U1 I FIRST CONTACT 6 Q 0•((Yes,See Sidebar 60110 0 3609643B IL 2024 it 0 cn n TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)689-4345 R524-7807-8193 IL D 1 FMEU31 E08UA31822 American Alliance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same I LAA-073777201 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ElRE Y NR Same u1 = (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(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 El AM Did crash occur ❑Y U2 Z N ® 11 1 9/ /6/ /024 04 28 ®pm in a Work Zone? ®N DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C) T 2 0 28 03 ! I 0 PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 CO 11 1 ARREST NAME RAMIREZ VILLA. Rene.O. 11-601 S017500051 I / / ❑PM SLMT o U 0CITATIONS ISSUED 0PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility rnII AM 35 I 2 ID1 1 1 ARREST NAME , / ptil El Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? El 35 475-Williams. Brianna 201 334-Fries 11 , 12/2024 09 00 0 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. Tx 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 'I I I I I. ; INDICATE NORTH combination)or —I 7:1 n BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I 1 i1 i ILT a ! ` 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------:-- -- 4 i } } i transporting employees in the course of their employment(example.employee M ,„--m•- transporter-usually a van type vehicle or passenger car).or w i____A____: : i , : r . 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N ) for direct compensation(example:large van used for specific purpose).or O __1 i , N. I t i ) i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires ` placarding(example placards will be displayed on the vehicle) 11 CARRIER NAME Z # ADDRESS 0 To CITY/STATE/ZIP Not To Scale I - MOTOR CARR ID ❑ Interstate ❑ Intrastate r , ( • 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. XI , Source of above Z . Form Number m 7a 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 >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 White u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑,r DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage 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