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HomeMy WebLinkAbout2024-00062768 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III I IIIIIII II 1111111111111101111HI 11101111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035743E0* u, 1 Uz 1 3 4 1 UI 7 U2 1 U, 1 U2 1 U,99 U2 99 1 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) [Z] B Injury and JorTow Due To Crash YR 2024I2024-00062768 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'i'i BLUFF CITY BLVD El In 0RELATED ®Y ❑N 10 01 2024 02'58 ❑AM ❑YES ®No u1 ,< g PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W ST ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑NCV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 5 / 2 4 J 2 0 0 6 FOR DAMAGED AREA(S) .FRONT TOWED Ut O , Ethan,J. BMW 328 2009 00-NONE 0..0../1 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE lJ FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� z DISTRACTED ® ❑ U2 0 m 1780 LANYON DR M ❑Y El NE DUNK VEH. O SYSTM ATCRASH D 0 99-15-UNKNOWN 9 16-TOP 3 Distraction Value 9 ALGN = THER W. CITY PLATE NO. STATE YEAR POINT OF 8 .FIRST CONTACT 12 7_.; 6- 4:_.5 •COM VEH ❑ ® 1 0 F Y Yes,See Sidebar U1 Z WBAPK73529A452433 Progressive ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Jimenez,Alphonso,C. 962926973 1 Ei HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r L RESPONDER II 1780 LANYON DR. BARTLETT. I L.60103 (312)301-1256 VEHU G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRctir TOWED Y N NAME(LAST,FIRST,M) Gills. Larry. M_ 0 mo8 0 ay 1 9 yr 9 Toyota Crown 2024 DO-NONE 'o) 12 Y RE o CRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR 1) a 194 PLEASANT DR M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 4 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1 4 COM VEH ❑ IN U1 CO F, FIRST CONTACT 6 Q . C Z South Elgin IL 60177 0 T428SJ UT 2025 TEAR 0•*Yes See Sidebar 4 fp M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)460-8894 G420-5337-9219 IL D 0 JTDAAAAF8R3022236 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I EAN HOLDINGS LLC 1747248SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < ONDE 0 Y NR 7144 S STATE ST. Midvale. UT.840471559 (801)736-7345 U1 = (UNITE (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL) n 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 ❑AM Did crash occur 0 Y U2 Z N ® 1 1 4 10/01 /2024 02 58 ®pm in a Work Zone? El DIRP co IN 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 0 Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 • ® 11 4 ARREST NAME Jimenez. Ethan.J. 11-1201-A- 1525000325 / / ❑PM SLMT o u CITATIONS ISSUED PENDING ROAD CLEARANCE TIME ❑Utility o N SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/01 /2024 03 25 RI RA0 Unknown work zone type Ut T • • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1525-Nava.Oscar 401 334-Fries 10 /22/2024 09 00 0 RA Workers present? ®N El Y 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. F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; I _r r A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1111401 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 I ; i ` ` INDICATE NORTH XI combination) or XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , L i_ I Not To Scale _J I 1 _I. i � ; (example.shuttle or charter bus)-or n ed to 5 or fewer ers and ct <____-t____; . ; J 1 I i } - t transporting employeeslin the course of their employment(example�emaployeerier M Unit ` transporter-usually a van type vehicle or passenger car).or w i 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 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m _ placarding(example placards will be isplayed on the vehicle) XI I. I ' l elunragvawa I unit CARRIER NAME Z ADDRESS 0 • cn I CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other 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 D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A 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 m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Black Gray u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X 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- 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE