HomeMy WebLinkAbout2024-00063583 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035;T;345
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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) 0 B Injury and JorTow Due To Crash YR 2024I2024-00063583 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT
RAYMOND ST ® ❑
Elgin RELATED ®Y ❑N 10 05 2024 02:56 EH,'" ❑YES ®No u1 ,<
PRIVATE mo /day I yr 0 PM FLOW CONDITION m
FT/MI N E S W BENT ST 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR 0 SLOW 15 N
❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF ) Kane HIT 8 RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0
tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) fitONi TOWED Ut O
M 0 9 / 2 4 J 1 9 3 1 Chrysler Town&Country 2007 00-NONE 0' ..0.,01 DUE TO CRASH ® ❑
, M.NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE El
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ® U2 2 m
669 N GREEN DR M SYTHER
❑Y ®N SE❑UNK VEH. O AT CRASH M IN ENGAGEDO 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
CITY PLATE NO. STATE YEAR POINT OF 8 . 6 4 C. VEH ❑ ® 1 n
ll FIRST CONTACT 1 7_ •I- ._5 ^Yves,See Sidebar U1 O
Z
2A4GP54L07R302880 Allstate ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
a Same 811412524 1 m
o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
'' RESPONDER Same VEHU
L ❑Y ®N 2 0
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑soy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m
m FOR DAMAGED AREA(S) R2ONT TOWED
NAME(LAST,FIRST,M) Y N
s Tolentino Mart ginez. Ed ar 0 8 / 1 4J 1 9 8 1 Chevrolet Tahoe 2007 00-NONE
13-UNDER CARRIAGE O. >2 O DUE TO CRASH (ffi 0 2
v mo day yr ail FIRE ❑ [2] U2 xi
, STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL ®-TOTAL(ALL) O DISTRACTED 0 ® SPDR 0
SYSTEM IN O ENGAGED O 15-OTHER 9 6 TOP 3O 9 0 X
E. 621 RAYM O N D ST M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN Df istraction Value
Nto
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COFONTACT 12 O7 a-Vd- ( ClOkes gee Sidebar❑ 21 U1 C
ELGIN IL 60120 B DL82072 IL 2025 0 Sn
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(224)281-5881 T453-2008-1231 IL D 0 1GNFK13027R170184 Kemper ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
Same 12AU001574526 BAC•
3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 <
0 POND
M N Same U1 =
(UNIT) (SEAT) (DOB( (SEX) (SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE( (EMSi (HOSPITAL)
2 4 02 /23/2317 M 2 6 B 4 0 Oliver Tolentino/621 RAYMOND ST,ELGIN.IL.60120 Elgin Fire Sherman U2 996
m
2 6 07 /1 4/2009 M 2 6 B 4 0 Edgar Tolentino/621 RAYMOND ST.ELGIN,IL.60120 El in Fire Sherman #occs >
(224)840-3473 _ g X
2 3 07 /29/1983 F 2 8 B 4 0 Beatriz Morales/621 RAYMOND ST.ELGIN.IL.60120 Elgin Fire Sherman U1 1 m
(224)281-5932 D
W 1 1 /29/1991 F Cristina A lannello/301 RIVERVIEW AVE .SOUTH ELGIN.1L60177/ 0
(224)253-3411 U2 4 Z
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y
N ® 11 1 10,51 /024 02 56 0 pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 3
a
2 ❑ 2 28 ! I 0 PM 0 Construction *
N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
Q CO 11 1 ARREST NAME Felske. Richard. M. 11-601-Ax 51526000227 / / ❑PM SLMT
o U CITATIONS ISSUEDPENDING •
ROAD CLEARANCE TIME ' ❑Utility
o N ❑ 0 SECTION CITATION NO. AM 30
2 0 ARREST NAME 10/5/ /024 04 00 ®PM 0 Unknown work zone type U1
T •
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1526-Walsh.Jacob 401 - 10 /28/2024 01 30 0 PM 0 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
_r } A CMV is defined as any motor vehicle used to transport passengers or property and.
D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r 'I 1 - combination) or 'I
INDICATE NORTH 7:1
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 0
N
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i------;-----% -i } - i transporting employees in the course of their employment(example.employee XI
transporter-usually a van type vehicle or passenger car).or w
i____-----_4 4 , i r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, u)
•[,1'
( for direct compensation(example:large van used for specific purpose).or
L____- ___-1 i . , ..�n -t i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires O
11
— _—— placarding(example placards will be displayed on the vehicle) 71
— m
1 I z CARRIER NAME—
I «�a .. ADDRESS 0
N
_Ivor To sow - 0
CITY/STATE/ZIP
r ,
MOTOR CARR ID ❑ Interstate ❑ Intrastate
( • 0 Not in Comm./Govt. El Not in Comm./Other
r ,
USDOT NO. ILCC NO. <
XI
, Source of above Z
. ❑ 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 ❑ No
MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No
Form Number 0
m
7a
IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S
TRAILER VIN 1 m
N
LOCAL USE ONLY TRAILER VIN 2 m
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
Blue Red
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED zr DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO ❑ Redmons/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE