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HomeMy WebLinkAbout2024-00062098 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 1111111 DIII III Ifi IIIIIII II 11111111111111011111 IIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35;T;319` u1 1 U2 1 1 1 U116 U2 U1 1 U2 U1 1 U2 1 5 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 1 0 NOT ON S VEHICLE/PROPERTY N OVER$1.500 ❑AMENDEDCENE(DESK REPORT) N B Injury and JorTow Due To Crash YR 2024I2024-00062098 VENT * ADDRESS NO. •HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I SYCAMORE ST ®gin ID ❑Y co" 09 28 2024 06'44 ®AM ❑YES ®No U1 .< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W ) Kane HIT&RUN El N N PEDALCYCUST N N ❑ FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED Ut 0 , Hender, M. 0 7 / 1 3 J 1 9 8 5 NT Toyota Corolla 2009 00-NONE ®i ©I , DUE TO CRASH El ® NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( 2 FIRE ❑ N 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 53 U2 m 1451 EXETER LN M SYM ❑Y ®SNE El UNK VEH. O AT CRASHD 0 99-UNKNOWN 9 56-TOP 3 .Distraction Value 9 ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF 8• !1 6 it 4 COM VEH ❑ El 1 0 ra )237-8835 1 NXBU40E89Z059976 NIA ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same NIA 1 o HOSPITAL(TAKEN TO) r INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU L ❑Y ❑" 2 G') 0 DRIVER ® PARKED 0 CRNERLESS 0 PED ❑PEDAL ❑EQUES 0 NUV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FROM TOWED Y N n NAME(LAST,FIRST,M) mo day yr Nissan NV 2021 oo-NONE it. 12 I /�DUE TO CRASH ❑ ® 98 Z1 a 13-UNDER CARRIAGE J FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 �,,O�DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 76-TOP® 0 ® SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 UI 9 POINT OF a . -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® to 1— FIRST CONTACT 2 7.-1-6 .5 •It Yes,See Sidebar C CQ96396 IL 2025 REAk0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 3N6CMOKN3MK703971 Zurich American ❑" N N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Burroughs Inc BAP-4513419-00 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y°ENR 558 LAMONT RD. Elmhurst. IL (224)401-6411 U1 = (UNIT' (SEAT) (DOBi (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/I ADDRESS)r(TELEPHONE) (EMS) (HOSPITAL) C) I I - U2 996 r m / / - '#OCCS > / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El Y U2 Z N 1 ® 18 3 Barcelona. Maribel.C. Grass located on property 09,28 ,2024 06 44 ❑pti, in a Work Zone? N 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 ❑AMU1 3 s 2 ❑ 2255 COTTONWOOD DR E LG I N IL 60123 08 99 / / 0 AM ❑Construction * N 3 ❑ N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q ARREST NAME Uribe Solano, Hender. M. 3-707 751597 / / ❑PM SLMT c U 1 ® 11 1 1 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility NAM 30 2 0 ARREST NAME Uribe Solano. Hender, M. 6-101-A 751598 r / 8 ptil El Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑Am workers present? 1532-Hernandez. Daniel 702 - r / ❑PM ® 30 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 ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. Tx Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. ', i -` ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -- -- i •2,. r r r transporting employees in the course of their employment(example.employee M 4 transporter-usually a van type vehicle or passenger car).or w __ , i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose).oroF 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) n CARRIER NAME Z ADDRESS 0 N ' _Not 7b l J 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 . ❑ 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 C Z Form Number 0 M 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N 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 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 2 ft. y Red White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 1 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE