HomeMy WebLinkAbout2024-00061980 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003569054
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
El NOT ON S
VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) 0 B Injury and JorTow Due To Crash YR 2024I2024-00061980 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT
HOPPS RD ® ❑
Elgin RELATED ®Y ❑N 09 27 2024 07:37 EH,'" ❑YES ®No u1 ,<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT/MI N E S W U M
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑CODES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRONT TOWED Ut O
, PEDRO, G. 1 2 / 1 6 J20 0 1 Honda Civic 1998 00-NONE 01 12I , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( I, 2 FIRE El ® 2 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ® ❑ U2 m
1724 W TO U HY AVE M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 56-TOP 3 ,Distraction Value 7 ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 8• 11 6 ii 4 COM VEH 0 ® 1 0
rA ~
1HGEJ8642WL007827 4475374197 0 Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
Same GEICO 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 0
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Y N
s MARIN-MONTILLA,ALEIDYS.C. 1 0 / 0 2 J 1 9 8 7 Ford Fiesta 2011 00-NONE
13-UNDER CARRIAGE O' All
D1 DUE TO CRASH M ❑ 2
mo day yr 10 II 2 FIRE ❑ [2] U2 C
xi
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ IN SPDR C)
a` 920 HELEN AVE F
SYSTEM IN O ENGAGED 0 15-OTHER 9 1
•DistractionValue
6-TOP 3 0
❑Y ® ❑N UNK VEH. AT CRASH 99-UNKNOWN
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 jII 1, 4 COM VEH ❑ ® U1 to
FIRST CONTACT 12 7___l 6 5 •If Yes,See Sidebar
Z SOUTH ELGIN IL 60177 B AV16148 IL 2024 0 tn
D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(727)598-2836 M655-0038-7881 IL D 3FADP4FJ6BM162144 ALLSTATE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
HERNANDEZ-VIGIL.JONATHAN 802-151-221 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
pO®N 1064 MORAINE DR.SOUTH ELGIN - IL.60177 U1 =
iUNITI (SEAT) IDOBi (SEX) i ISAFTI (AIR) IINJI (EJCT' (EPTH) PASSENGERS&WITNESS ONLY (NAME'HADDRESS)?iTELEPHONE) i EMS (HOSPITAL)
1 4 04 /08/2014 F 2 4 0� 1 0 ISABELLA M. RANDS/1724 W TOUHY AVE.CHICAGO,IL,60626 Elgin Fire Refused U2 996
(815)355 5290 m
1 3 06 /07//2009 F 2 4 0 1 0 ZOEY HAYES/1724 W TOUHY AVE.CHICAGO-IL-60626 Elgin Fire Refused #Dccs y
(815)355-5290 _ g >
/ / u1 3 m
/ 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 09/27 /2024 07 37 ®pM in a Work Zone? ElN DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1
2 ❑ 2 99 09,27 /2024 07 37 ®PM El Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
Q ARREST NAME SANTIAGO, PEDRO,G. 11-901-A s1533-000143 09/27/2024 07 42 ®PM SLMT
1 CO 11 1 ❑Utility
p U ❑CITATIONS ISSUED El 'SECTION CITATION NO. ROAD CLEARANCE TIME
N AM 30
2 0 ARREST NAME 09,27 /2024 08 05 ®PM 0 Unknown work zone type U1
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1533-Ruiz Jose 702 322-Schroeder 11 , 12/2024 09 00 0 PM workers present? ®N U2 30
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
_r } A CMV is defined as any motor vehicle used to transportproperty and.passengers or D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I combination).or —I
INDICATE NORTH XI
I 1 ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
.,, +, + N -! ` r r r (example'.shuttle or charter bus)-or
Not To Scale 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i.-----;------i 4 i } - i transporting employees in the course of their employment(example.employee M
Nomevs transporter-usually a van type vehicle or passenger ca) w
r.or
r i 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
;,____i____; ; ; — — _._— — —UNIT? — _— — _ — i. i. < 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
M
` placarding(example placards will be displayed on the vehicle) 71
CFI4 1 ':, [
I CARRIER NAME Z
' I ADDRESS 0
N
raracuarro O
CITY/STATE/ZIP
•
r ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
0 Not in Comm./Govt. El Not in Comm./Other
r , USDOT NO. ILCC NO.
, Source of above Z
_ own tank)? ❑ Yes ❑ No ❑ Unknowr D
Did HAZMAT Regulations violation contnbute to the crash? r
❑ Yes ❑ No ❑ Unknown g
Did Carrier Safety Regulations(MCS)violation contribute to the crash? O
❑ 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
Form Number 0
rn
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
Green Red
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 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