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HomeMy WebLinkAbout2024-00062173 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III (III IIIIIII II 11111111111111111111111111110111111 Ci DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0O356 4 u, 1 U21 1 1 1 U199 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 1 *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 [23 NOT ON S❑ON SCENE 15 VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2O24I2O24-00062173 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 N MCLEAN BLVD El ❑in RELATED ®Y 0 N 09 28 2024 04:48 ❑AM El ®No u1 ,< g PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W M I LD R E D ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ❑ FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED O PEDAL ❑EOUES 0 NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0_ TOWED U1 NAME(LAST,FIRST,M) Perez,Jensy,Y. mo day yr Ford Escape 2010 00-NONE 11 1z , DUE TO CRASH ❑ 13-UNDERCARRIAGE 10 21 1 I 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 6 m 771 PINE ST F ❑Y IN NSYSTEM DUNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF 6 f� e l 4 COM VEH ❑ ® 1 O A ~ 1 FMCU9D71AKC44335 Bristol West ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Lopez, Marco G01443021900 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r L RESPONDER 771 PINE ST, ELGIN , IL,60123 (773)870-6141 VEHU G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGEDAREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Gasca, Ignacio mo day yr1 0 0 $ 2 0 0 1 Chevrolet Colorado Pickup 2017 00-NONE +c) 12 ' s DUE TO CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X a` 155 S BELMONT ST M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Oistract(on Value 6�1�/�� 4 COM VEH ❑ ® UI N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F FIRSTPOINT CONTACT 6 7_•d_4'.�'_,_._5 ••fryer,See Sidebar to H ELGIN IL 60123 0 2510150B IL 2024 RFC 0 CC/1 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)400-1295 G200-4000-1287 IL D 1GCGTBEN6H1235093 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Gasca,Alma. D. 0149061 SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YRESPONDER 155 S BELMONT AVE, ELGIN , IL,60123 (224)305-2709 U1 = (UNIT) (SEAT) (DOB) /SEX! ;SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME),I ADDRESS)U(TELEPHONE) (EMS) (HOSPITAL) Walter J. Carcamo Perez/ 996 1— 1 3 05 /03/2001 M 2 3 0 1 U2 m / I #occs y / / U1 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y U2 Z N ® 11 1 09/28 /2024 04 30 ®pm in a Work Zone? ®N DIRP co 1 I 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 03 99 / / 0 PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q CO 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U CI CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 0 ARREST NAME , / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 25 558-Lara, -izette 501 246-Kite , / 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. r IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I . 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 ' ._ I ', ! i ._ ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------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 ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , Source of above Z . 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 Blue White - 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE