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HomeMy WebLinkAbout2024-00063145 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III 11111 II X0035T;;36111111111111110111111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY 3� u, 1 U21 2 4 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) Ill B Injury and JorTow Due To Crash yR 202412024-00063145 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT N MELROSE AVE ❑ Elgin RELATED ®Y ❑N 10 03 2024 1220 ❑AM ® ❑YES NO U1 -< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E 5 W W CHICAGO ) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 ECUES ❑NIN ❑Rcv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 6 / 2 3 /1 9 9 8 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mo day yr . Eric Chevrolet Express 2004 00-NONE 11 12 , DUE TO CRASH 0 13-UNDER CARRIAGE t FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 ID FIRE 0 ® U2 2 m 20 ALLEN DR M THER ❑Y ❑N SYSE El UNK VEH. 9 AT CRASH M IN ENGAGED9 99-UNKNOWN 9 16-TOP® Distraction Value 9 ALGN = T. CITY PLATE NO. STATE YEAR POINT OF 6_II 6 li O COM VEH ISI ❑ 1 O ~ 1GCHG35UX41192507 Elite Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a TFoss Enterprise 6716903 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER o RESPONDERN 563 COMMONWEALTH DR 1700. EAST DUNDEE. IL.60118 (224)368-7212 VEHU GI 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 14 m m / / FOR DAMAGED AREA(S) ©FRONT O TOWED DUE TO RASH Y N S Re es Fiore- Laura. E. 0 4 3 0 1 9 8 4 Audi Q7 2010 00-NONE , , II 0 2 —I 73 NAME(LAST,FIRST,M) y mo day yr 1;0 O, 2 FIRE ❑ ® U2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 9 0 a` 90 DICKENS TRL F ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RIST COONTACT F 12 7. 6 5 ClrveeVSee Sideba❑ ® U1 C to F- ELGIN IL 60120 0 BG75640 IL 2025 REAR 0 Sn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)508-4280 R214-5258-4696 IL D WA1VMAFEOAD000779 Kemper Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Hernandez.Sergio 12RA000001793 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER ON 31 S CLIFTON AVE. ELGIN . IL.60123 (224)805-3846 Ut = (UNIT' I SEAT) (DOB) (SEX) i)SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME i/(ADDRESS)/(TELEPHONE) IEMSI (HOSPITAL) 2 4 05 /1 4/2008 F 2 4 B 1 0 Alondra Hernandez/90 DICKENS TRL,ELGIN-IL-60120 Elgin Fire Provena St.Joseph U2 996 1 (224)508-3373 m 2 6 05 /0 9/1960 F 2 4 0 1 0 Gregoria Flores/90 DICKENS TRL-ELGIN-IL-60120 Elgin Fire Provena St.Joseph #occs D (224)508-4280 _ X 2 3 04 /0 3/1957 M 2 4 0 1 0 Carlos Machado-Reyes/90 DICKENS TRL.ELGIN.IL.60120 Elgin Fire Provena St.Joseph Ut 1 m (224)508-4280 D / I 4 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 ® 11 1 10/31 /024 12 20 0 pm in a Work Zone? ®N DIRP D 1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 1 2 0 23 2 10,31 /024 12 24 ®PM El Construction * c' 3 ❑ izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 0 AM ❑Maintenance U2 ® 11 1 ARREST NAME Gomez. Eric 11-601 483000278 10/3/ /024 12 28 ®PM SLMT o U CITATIONS ISSUED PENDING ROAD CLEARANCE• TIME 0 Utility o N SECTION CITATION NO. AM 35 2 ❑ ARREST NAME 1 0/3/ /024 12 50 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 0 AM Workers present? ❑Y 35 483-Lynch, Miriam 600 272-Bajak / / 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. _ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS D ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. �r0 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer combination)or —I r ; ', 1 I I r INDICATE NORTH .X0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ', ', i �—*� -t ` r r r (example'.shuttle or charter bus)-or r7 X s 0, 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 <-----`----', , 9 9 P by } } } transporting employees in the course of their employment(example employee M ... __ transporter-usually a van type vehicle or passenger car).or 03 I r:— ) SAD _: 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 L____-L____1 , "N -: i } i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires "'""'"" placarding(example placards will be displayed on the vehicle) M XI e I~ Not To Scale CARRIER NAME Z IADDRESS 0 N s414 • CITY/STATE/ZIP I 0 r , MOTOR CARR ID ❑ Interstate El Intrastate . 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . own tank)? ❑ Yes ® No ❑ Unknowr Did HAZMAT Regulations violation contnbute to the crash? r ❑ 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 ® :::. - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ®No Form Number 0 rn 7a IDOT PERMIT NO WIDELOAD? ❑Yes ®No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m l7 TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 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- 2 TOWED BY/TO: SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED ,r DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE