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HomeMy WebLinkAbout2024-00063042 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III Ifi IIII lull 1111111111111101111HI 1111 III I II II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XDO3574351 u1 1 U2 1 1 1 U144 U2 1 U1 1 U2 U1 99 Uz 99 4 9 U1 1 U221 *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 S VEHICLE/PROPERTY EnOVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00063042 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 CLAYTON AVE ❑ Elgin RELATED ❑Y coN 10 02 2024 08:11 EH,'" ® ❑YES NO u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 2 f/) ❑ FT/MI N E S W 'WITH VEHICLES INVLD El STOPPED U2 —1 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 ERNERLESS ❑ PED ❑PEDAL ❑EOUES 0 NIA/ ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n O 3 / O 4 J 1 9 9 6 FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) Elbir. Eder mo day yr Hyundai Accent 2010 00-NONE Q.i O..D1 DUE TO CRASH ® ❑ 13-UNDERCARRIAGE FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1D O DISTRACTED ® ❑ U2 2 m 262 CHAPARRAL CIR M ❑Y ESYlM DUNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP® ,Distraction Value , ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 i 6 ii 4 COM VEH 0 El 1 C) m FIRST CONTACT 1 7__�_�5 •Yves,See Sidebar U1 0 • Z KMHCN4AC9AU458821 Direct Auto ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Montero.Annel PAIL001114210 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER II 33 VEN ETO CT,STREAMWOOD . I L,60107 (630)478-1010 VEHU G1 0 DRIVER ta PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) mo day yr Mazda Sport Truck 1997 00-NONE it 12 ,_t DUE To CRASH ❑ ® 1 Z1 c 13-UNDER CARRIAGE 10 i I 2 FIRE ❑ Ill U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 A': SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ©1 14 COM VEH 0 ® U1 to 1— FIRST CONTACT 7 Q •It Yes,See Sidebar 13990WB IL 2025 PEAR 4 CC/) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4F4CR16A8VTM23320 State Farm ❑V ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Acevedo,Jesus, H. 1547837SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NR 212 GORDON CT. ELGIN . 11_60123 (630)774-3548 U1 = (UNIT) (SEAT) (DOB) ISEXI ISAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 r m / / - #OCCS y / /• U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N 1 ® 18 1 10/02 /2024 08 38 ®pm in a Work Zone? El DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 5 C) T 2 0 44 28 ! / 0 PM El Construction * N 3 0 izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 •Q El 11 1 ARREST NAME Enoczelaya Elbir, Eder 12-610.2-B 1525000329 / / ❑PM SLMT oN ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME AM' ❑Utility 30 2 0 ARREST NAME Enoczelaya Elbir, Eder 6-101 1525000330 10/02 /2024 09 30 ®PM 0 Unknown work zone type Ut 'r • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1525-Nava,Oscar 501 334-Fries 10 /22/2024 09 00 D PM Workers present? ®N 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. D F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. ' j (rip1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r r1 ; ' ' 1 N ` ` INDICATE NORTH combination) or —I XI d I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', ', i Not To Scale I. ` r r r (example.shuttle or charter bus)-or 0 i_. ...----- i i t , i designed employeeslin the courseaof theirem^d merit(example�emaployeerier Xl 3. Is , f } trans �II transporter-usually a van type vehicle or passenger car).or w , " i , : i r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C I ; ; for direct compensation(example:large van used for specific purpose).or O I , Q O E i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) X. V a r et I CARRIER NAME —i ' ' !fit I .. ADDRESS 0 . To y O 1 CITY/STATE/ZIP • : - MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other USDOT NO. ILCC NO. m , Source of above 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% A ❑ Yes No ❑ Unknown 0 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 D m XI IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Maroon Maroon 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