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HomeMy WebLinkAbout2024-00063157 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIIIIII II 11111111111111011111 III 010 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035,T731r u, 1 U21 3 4 1 U1 1 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 U1 3 U211 *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 EI NOT ON SVEHICLE/PROPERTY El OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063157 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'T'I CHAPARRAL CIR Elgin ID ❑Y coN 10 03 2024 0116 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 1 D 0/MI N E s SHALES Pk COUNTY PROPERTY ❑Y ®N DOORING El #OF MOTOR ❑SLOW 15 co ® ® © ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 ARV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 4 / 0 7 /1 9 4 9 FOR DAMAGEDAREA(S) FRONT TOWED U1 mo ,AWILDANissan Sentra 2009 00-NONE ®i 12I , DUE TO CRASH p NAME(LAST,FIRST,M) day yr 13-UNDER CARRIAGE ( I, 2 FIRE ❑ IA 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DI ® DISTRACTED 0 EI U2 m 214 CHAPARRAL CIR F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN O9 16-TOP 3 ,Distraction Value 9 ALGN I r CITY PLATE NO. STATE YEAR POINT OF 6 )I _ Ii 4 COM VEH 0 ® 1 0 ~ 3N1AB61E29L648003 TRAVELERS ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 1 99 9 DEL CASTRO_ MATAIS 6151845512031 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER > o RESPONDER II 9 214 CHAPARRAL CIR. ELGIN . I L.60120 (847)857-8711 VEHU G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED CRasH Y N s NAME(LAST,FIRST,M) ZELAYA ELVIR,JEIMY 0 0 Oda 1 9 9 8 Ford Edge 2008 00-NONE a 1'_+ 0 ® 2 Xi a 13-UNDER CARRIAGE 10 j ©I I s FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) E 260 LINCOLN AVE F SYSTEM IN 0 ian ENGAGED 0 15-OTHER 9 +6-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •DistracValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 12 7. t_6_ ,5 C•IOMeeVSee Sidebar ® U1 to ~ ELGIN IL 60120 0 EE55454 IL 2024 " 0 S.n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)689-2945 Z441-4209-8789 IL D 0 2FMDK38C88BA79967 AMERICAN FREEDOM ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 Same 12-2418606-00 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER E 9 Same ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - #OCCS y / /• U1 1 m I I 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 10,03 /2024 01 16 ®pM in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 8 C) T 2 0 18 99 ! / 0 PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance uz 3 Q CO 11 1 ARREST NAME / / ❑PM ❑Utility SLMT p U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N IIAM 25 2 0 ARREST NAME 1 / ptit ❑Unknown work zone type Ut r,f Co T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 374-Rizzu-o, Michael 302 272-Bajak , / 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. _ 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. D Z 3HALES?PKWY 1 Has a weight rating more than 10,000 pounds(example.truck or truck/trailer ' r 1 - i -; ; combination) or INDICATE NORTH 711 ( 1 I I I ( BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` ', ', i - _t i r r r (example'.shuttle or charter bus)-or 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.-----i_-----f 4 1 -i } - i transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or 03 `- "`""_-' ' , Not To Scale J i i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N CHAPARRAL?CIR " ( for direct compensation(example:large van used for specific purpose).or L____L____; , , J i 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m Vi1gpr placarding(example placards will be isplayed on the vehicle) 71 Z N��� CARRIER NAME Z ' pO ADDRESS 0 • N _ • • • CITY/STATE/ZIP O MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , , 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? O ❑ 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 5 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 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Red White - 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 1 TOWED BYfTO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE