HomeMy WebLinkAbout2024-00062914 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 OIl III I IIIIIII II 11111111111111111111lll11Illlllll I
I
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003574340'
u, 1 U21 1 1 1 U116 U2 1 U, 1 U2 1 Ut 1 U2 1 1 13 Ut 1 U2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE •
4
El NOT ON SVEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00062914 VENT *
ADDRESS NO. HIGHWAY or STREET NAME • CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
LARKIN AVE ❑Elgin RELATED ❑Y coN 10 02 2024 08:40 ®AM ❑YES ®No u1 ,<
PRIVATE mo /day I yr El PM FLOW CONDITION m
Lyle 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U)
23.25 FT N O S W S AveA WITH VEHICLES INVLD ElSTOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRNER 0 PARKED 0 DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 6 / 2 3 J 1 9 5 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut O
.Agripina BMW X3 2011 00-NONE ®i 12 , DUE TO CRASH ® ❑ E
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( _. 2 FIRE El ® 4 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ‘13) DISTRACTED ❑ ® U2 m
1158 I N D IAN DR F ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF 6 !1 6 it 4 COM VEH 0 ® 1
0
rA
5UXWX5C52BL702962 State Farm ❑Y ®N U2 m
V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Same 2927000-SFP-13 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >
'' RESPONDER Same VEHU
L ❑Y ❑N 2 05' ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m / J FOR DAMAGED AREA(S) f720IT TOWED
Y N
s NAME(LAST,FIRST,M) GASPAR MEJIA_ MODESTO.O. 0 6 lday 1 9 yr7 2 Toyota Camry 2017 00-NONE Q' 12 I. , fffi ❑ 2Xi
. mo13-UNDER CARRIAGE 0 t j 2
FIRE ❑ 21 U2 C
v
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ❑ ® SPDR 0
SYSTEM IN O ENGAGED 0 15-OTHER 016-TOP 3 0 X
❑Y ® El 320 JOHN DR M N UNK VEH. AT CRASH 99-UNKNOWN •Oistrachon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 O 7_ 6 5 COM VEH ❑ ® U1to
C
F. - 'If Yee,See Sidebar
ELGIN IL 60120 0 ED89985 IL 2025 0 fn,
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(847)483-4814 G216-5547-2170 IL D 0 4T1 BD1 FK1 HU210926 INTEGON CASUALTY ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Same 2024121602 BAC
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
0RE Y 0 NR Same U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
I I U2 996 1-
m
- '#OcCS >
/ /• U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ElY U2 Z
N 1 ® 11 1 10,02 /2024 08 40 ❑pti, in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME El AM It YES check one below: U1 7 C)
T 2 ❑ 20 15
/ / 0 PM El Construction *
r�:A T 3 ❑ igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
Q El 11 1 ARREST NAME Valdez-Sanchez.Agripina 11-708 SO471-000117 / / ❑PM SLMT
o U ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
N AM 30
2 0 ARREST NAME Valdez-Sanchez.Agripina 6-101-A SO4 71-0 0 011 8 r / 8 ptil ❑Unknown work zone type Ut
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
471-Evans. Lakysha 602 - 11 r 12/2024 09 00 p 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.
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 D
.
Z
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r 1 i i combination) or
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i ', ', i I. r r r (example shuttle or charter bus) or
3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i_-----;-----� 4 i 4 -f r - t transporting employees in the course of their employment(example.employee ,3
- - transporter-usually a van type vehicle or passenger car).or w
i r. 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example.large van used for specific purpose).or O
U+R2 WITICuwm 1 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
'6. CARRIER NAME
' I ADDRESS 0
'• Nor 7b sera ) To
En
0
• 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
❑ 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 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
Silver White
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑zr 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