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HomeMy WebLinkAbout2024-00063092 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill III )III IIIIIII II 11111111111111011111111111111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;322" u1 9 uz 1 3 4 1 U1 2 U2 1 U199 U2 1 U1 99 U2 1 2 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S 0$501-$1,500 ®ON SCENE 2 0 NOT ON S VEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00063092 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 S STATE ST ❑Elgin RELATED ❑Y coN 10 03 2024 0611 ®AM ❑YES ®NO U1 .'< PRIVATE mo /day I yr ❑PM FLOW CONDITION m O 'COUNTY PROPERTY El Y ®N DOORING ❑y #OF MOTOR ®SLOW 1 U1 02 ®I MI ON E S W Lord St 'WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®'' ❑ N PEDALCYCUST®N 0 FREE FLOW # LNS 0 D4 DRNER 0 PARKED 0 CRNERLESS ❑ PED 0 PEDAL 0 EOUES 0 NIA/ ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGED AREA(S) FRONT TOWED U1 0 / / Unknown Unknown 00-NONE ©' ..0..0 DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE 0 lSi SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3DISTRACTED 0 10 U2 2 m ion r PLATE NO. STATE YEAR 6 1 00 F ID VIN INSURANCE CO. EXPIRED 1 Unknown ❑Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y 99 9 Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 99 0 5 ®COINER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Cervantes.Angelica 0 o lday yr 9 1 9 9 1 Toyota Camry 2018 00-NONE 1G) 1$ 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 ® SPDR 0 a` 2340 HORNED OWL CT F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s j (Ali,COM VEH 0 ® U1 F, FIRST CONTACT 6 7__. •If Yes See Sidebar ELGIN IL 60123 0 EM87942 IL 2025 iitaR M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)735-9589 C615-0139-1681 IL D 0 4T1 B61 H K1 J U 131155 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Ortiz. Ray. D. 1154210SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < POND 0 NI N 2340 HORNED OWL CT. ELGIN . IL.60123 (224)723-0420 Ut = (UNIT) I SEAT) (DOB) )SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME /'ADDRESS)/(TELEPHONE) (EMSi (HOSPITAL) 2 6 12 /27/2018 M 2 4 0 1 O Silas K. Ortiz/2340 HORNED OWL CT,ELGIN,IL,60123 Refused 996 r (221)735-9589 , U2 m / / #OCCS D / / Ut1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ®Y U2 Z N ® 11 1 10/03 /2024 06 12 ❑pM in a Work Zone? ❑N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: Ut 5 0 T 2 ❑ 28 99 ❑AM ! , 0 PM in Construction * c' 3 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 0 AM ❑Maintenance U2 Q 1 ® 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U CI CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N BAM 30 2 ❑ ARREST NAME / / PM ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME present? ®Y 30 495-Sjodir.Jacob 701 272-Bajak / , El 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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS UrYt? il " > ' 0 -� } A CMV is defined as any motor vehicle used to transport passengers or property and. 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. J. d i -` r r r (example.shuttle or charter bus)-or n X JUnR? 3 Is designed to carry 15 or fewer passengers and operated a contract carrier 0 i------i-----', ' 9 P by } } } transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w :____A____: : , — — i r 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 0 • ' ___I 1 . , 1 ( : } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' ADDRESS 0 N ' • - r • • • •i • F CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate Not Comm./Govt. ❑ Not m Comm./Other QmNOtToSa8lB - USDOT NO. ILCC NO., Source of above Z . 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? ID 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 Form Number 0 rn IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N 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 - 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