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HomeMy WebLinkAbout2024-00062936 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III HI III ll II 1111111111111101111111111111110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035/4339- u, 1 U21 2 3 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 1 *P 0119* 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 1 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00062936 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 RENNER DR ®gin El ❑" co" 10 02 2024 10'34 ®AM ❑YES 0 NO U1 PRIVATE mo /day I yr ❑PM FLOW CONDITION m 0 /MI N E S W BerkleySt 'COUNTY PROPERTY ❑Y ®" DOORING ❑y #OF MOTOR ❑SLOW 15 co ® O WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EOUES ❑NW ❑NCV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 Aguirre, Marco, R. 0 3 / 2 9 /1 9 7 1 Toyota Corolla 2022 00-NONE 11 DUE TO CRASH p 21 -NAME(LAST,FIRST,M) g mo day yr 12 O E 13-UNDERCARRIAGE io) 2 FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 j U2 2 m 2120 HASSELL RD 308 M ❑Y El NSYSTEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 Distraction Value ALGN I CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii-4 COM VEH 0 El 1 0 ~ 7MUCAABG3NV032980 State Farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 3343939-SFP-13 1 "6" HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU X L . ❑Y ®" 2 0 5 ®DRIVER ElPARKED 0 DRNERLESS ElPED 0 PEDAL ❑EQUES 0 WV ❑NCV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m FOR DAMAGED AREA(S) T TOWED NAME(LAST,FIRST,M) s Baxter,Vasiliki, B. 1 2 / 1 6 /1 9 6 6 Honda CRV 2018 00-NONE 1t.FRONT DUE TO CRASH ❑ ® 2 XI ©,mo day yr t3-UNDERCARRIAGE ll FIRE ❑ ® U2 C 2 10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) Y DISTRACTED 0 IN SPUR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X (2/k 3204 PIN EVI EW CIR F ❑Y N ❑UNK VEN. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO F RIST CONTACT F 12 7_'1 a 1_5 CO M •Ife6VSee Sidebar ® U1 al 1- 60110 B Z408031 IL 2024 REAR C 0 (/) n TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)520-1147 B236-8626-6957 IL D 0 2HKRM4H50FH702835 Lemonade ❑Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Baxter.Garifalia LCP942-2822-654 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 3204 PINEVIEW CIR.60110 U1 = (UNIT/ (SEAT) IDOB) (SEX) ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS),(TELEPHONEI (EMS) (HOSPITAL) 2 3 01 /1 8/2002 M 2 4 0 1 0 John R. Boxer/3204 PINEVIEW CIR,60110 Refused 996 ,- (224)520-1146 , U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N i ® 11 1 10,21 /024 10 34 ❑pM in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AMU1 1 a, 2 0 2 2 ! / 0 PIA ❑Construction * c' 3 ❑ igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ARREST NAME Jimenez Aguirre, Marco, R. 11-902 5348-001337 / / ❑PM SLMT ® 11 1 • ❑Utility p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 ❑ • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 348-Rapacz,Jordan 702 404-Duffy 11 , 19/2024 01 30 0 PM IZI 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. _ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS , w _, A CMV is defined as any motor vehicle used to transport passengers or property and Z ®A j 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I ; 1 combination).or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. I d i et -t ` r r r (example shuttle or charter bus) or n S i.. . + N -i } - i 3. Is transporting R!ng employeesed to l5 or fewer in the course theirem rs and operated (example�emact ployeerier .ZOI transporter-usuall a van type vehicle or passenger car).or 03 �____A____: : , , i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N ZI 0 for direct compensation(example:large van used for specific purpose).or 7 I ; ; ; y .... Berkley?St t < < ,, 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m Not s I CA"4 placarding(example placards will be displayed on the vehicle) 71 Unit 1 I CARRIER NAME Z ' ADDRESS 0N O CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate Renner?Dr. ❑ Not in Comm./Govt. El Not in Comm./Other OO ' USDOT NO. ILCC NO. C , Source of above Z • . If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No P3 73 m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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? JD 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 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 White Black - 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