HomeMy WebLinkAbout2024-00061940 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III (III IIIIIII II 11111111111 11011 11111110 1111110 I
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035690 9*
u, 1 U2 1 1 1 ui 2 U2 u1 1 U2 u1 1 U2 1 1 u1 1 U2 2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 13
0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00061940 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '�'1
INVERNESS DR ® ❑
Elgin RELATED ❑Y co" 09 27 2024 03:55 ❑AM ❑YES ®No u1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑Y #OF MOTOR ®SLOW CI)
❑ FT/MI N E S W Cook ❑Y , , WITH VEHICLES INVLD ❑ STOPPED U2 —1
❑ AT INTERSECTION W HIT&RUN WITH (NAME OF ) PEDALCYCUST El 0 FREE FLOW # LNS 0
tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 5 / 0 1 /2 0 0 4 FOR DAMAGED AREA(S) FRONT TOWED U1
clop Honda HR-V 2019 00-NONE 0' ..72..D DUE TOCRASH 0 fzi
NAME(LAST,FIRST,M) p mo day yr 13-UNDER CARRIAGE FIRE 0
El
SEX SAFT AIR AUTOMATION LEVEL LEVEL 1144-TOTAL(ALL) �� 2 DISTRACTED 0 I U2 O m
1277 INVERNESS DR M ❑Y ESYlM❑UNK VINEH. O AET CRASHD 0 99-UUNKNOWN THER 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8 . 4 COM VEH 0 El m jL FIRST CONTACT 12 7_.; 6-:_.5 •Yves,See Sidebar U1
0
Z
3CZRU5H78KM714222 Geico ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Villegas,Anthony, E. 6165169167 1
Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r
o RESPONDER 760 ST CHARLES ST. ELGIN - I L,60120 (312)530-2387 VEHU G1
m ❑DRIVER 0 PARKED 0 CRNERLE55 x PED ❑PEDAL 0 EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
m / / M
1 9 FOR DAMAGED AREA(S) FRO TOWED
O CRasH Y N
NAME(LAST,FIRST,M) Villegas,Anthony, E. Omo day yr
2 Unknown Unknown 00-NONE ,t` ,2 , 1 ❑ 21
v 13-UNDER CARRIAGE 10 !
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 FIRE El El U2 CDISTRACTED 0 IZI SPDR 0
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 E 760 ST CHARLES ST M ❑Y ❑N ❑UNK VEH. AT CRASH ® UNKNOWN •Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 Ij 4 COM VEH ❑ 21 U1 to
C
H FIRST CONTACT 99 7. . 6 " .5 •If Yes,See Sidebar
ELGIN IL 60120 0 N/A Unknown RFC- 0.3
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(312)530-2387 V422-0059-2128 IL D 0 Not Applicable ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
1 64 5 Not Applicable BAC 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
DYO0N Ut I
(UNIT' (SEAT) (DOB( (SEX) (SAFT( (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
I I U2 996 1-
m
/ / - #OCCS y
/ / U1 1 m
/ I 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z
N ® 12 5 09/27 /2024 03 55 ®pM in a Work Zone? El DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 5
T 2 ❑ 28 99
! / PM El Construction *
N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2
Q 1 CO 12 5 ARREST NAME / / ❑PM ❑Utility SLMT
p U ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o N 8AM 10
2 El ARREST NAME / / ptil ❑Unknown work zone type Ut
T •
• OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 10
485-Quintana,Josue 302 334-Fries / / ❑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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
0
ADDITIONAL UNITS FORMS
' } A CMV is defined as any motor vehicle used to transport passengers or property and. Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z
r • ; i ; i- r r , , i INDICATE NORTH combination).or —I
• XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
', ', ! ' ' 1 ', ' f ` r r r (example'.shuttle or charter bus)-or n
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; I I ;
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------.-----• + + • : - -, 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 w
' 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 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example placards will be displayed on the vehicle) 11
•
CARRIER NAME Z
' ADDRESS 0
N
. O
• CITY/STATE/ZIP 0
. - MOTOR CARR ID ❑ Interstate El Intrastate
'
❑ Not in Comm./Govt. ElNot in Comm./Other Q
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r-----.-----, r r r r r----, r - DO ILCC NO. m
U N XI
, Source of above Z
. 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
0
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
Black
-
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO
SELECT CODES FROM THE BACK OF CRASH BOOKLET
u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE