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HomeMy WebLinkAbout2024-00063115 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II II 1111111111111101111HI 111111 11 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35;4356 u, 1 U2 1 1 1 1 U1 9 U2 1 U, 1 U2 1 U1 1 U2 1 1 16 U123 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE • 1 El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2O24-00063115 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 RAYMOND ST ❑Elgin RELATED ❑" co" 10 03 2024 08:59 ®AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m N 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ®/MI O E S W Ma Y St WITH VEHICLES INVLD ElSTOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NrN ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 4 / 0 9 /1 9 6 8 FOR DAMAGEDAREA(S) FRONT TOWED U1 ,G. Honda Pilot 2009 00-NONE „ 12 , DUE TO CRASH p 21 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 556 RAYM O N D ST F SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0D 99-UNK 15- NOWN 9 76-TOP 3 ,Distraction Value ALGN = THER r CITY PLATE NO. STATE YEAR POINT OF 8 lII 6 'I 4 COM VEH 0 El 1 0F FIRST CONTACT 5 7_-{ © "&Yes,See Sidebar U1 0 Z 5FNYF48929B015819 State Farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Baeza, Martin 0534405-SFP-13 1 `aHOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r o RESPONDER y°®EN 556 RAYMOND ST. ELGIN , IL.60120 (224)629-1522 VEHU > ' ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m 1 / / FOR DAMAGED AREA(S) Mao TOWED Y N , NAME(LAST,FIRST,M) Verde Luna. Hermes. M. Imo ld 6 1 9$8 Toyota Camry 2013 00-NONE 11 12 2 FIREETocRasH ❑❑ ® Uz 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ IN SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER ®16-TOP 3 0 X a` 459 CENTER ST M ❑Y (2/ N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value NT F U1 N CITY STATE ZIP IN) EJCT EPTH PLATE NO. STATE YEAR FIR I8T COONTACT 9 7_11 a 1_s C•IOMe6 3eeSidebarH ❑ ® to H ELGIN IL 60120 0 DW45351 IL 2024 REAR 0 PC/) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)454-6970 V634-3338-8326 IL D 0 4T4BF1 FKODR289385 Direct Auto ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same PAI L001064474 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y El NR Same Ut = (UNIT) I SEAT) (DOBi (SEX) )SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME!/-(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) 1 3 03 /1 8/1974 F 2 4 0 1 0 Josetina Villagomez/556 RAYMOND ST,ELGIN,IL,60120 Refused 996 m uz m / / #OCCS D / / u1 2 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 11 1 10/3/ /024 08 59 ❑pM in a Work Zone? El N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 3 C) T 2 ❑ 30 2 ❑AM c' 1 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 0 PM El Construction1 * ❑AM ❑Maintenance U2 Q ARREST NAME Baeza. Maria,G. 11-1102-A W319001061 / / ❑PM SLMT CO11 1 ' ❑Utility p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME orkers present? El Y 30 319-Ross.Adam 401 404-Duffy / / 0 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. r 0 IF 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. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i ; i r r , , 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 ', ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - -, 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or CO ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires mV placarding(example placards will be displayed on the vehicle) CARRIER NAME Z ' ADDRESS 0 N , O • CITY/STATE/ZIP 0 . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . ❑ Yes 0 No ❑ Unknown A 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 m TRAILER 1 ❑ ❑ ❑ z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Maroon Blue-Light - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE