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HomeMy WebLinkAbout2024-00063601 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III II 0 lull 11111111111111011111 III Ill Ill II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035;T;3E1 u, 1 U21 1 1 1 UI 7 U2 1 U, 1 U2 1 u1 1 U2 1 1 11 u1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063601 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 -n N LIBERTY ST ® ❑ Elgin RELATED ❑Y coN 10 05 2024 04:07 EH,'" ❑YES ®No u1 -< PRIVATE mo /day I yr ®PM FLOW CONDITION m ®1 0 ®I MI N E OS W DIVISION St COUNTY PROPERTY ❑Y ®N DOORING 0 y #OF MOTOR 0 SLOW 2 N Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg oRNER 0 PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL 0 EOUES 0 nuv 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 4 / 1 3 /2 0 0 4 FOR DAMAGED AREA(S) RtCNT TOWED U1 .J. Ford F150 2001 00-NONE ©' ..©.,0 DUE TOCRASH p ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 z DISTRACTED 0 El 2 m 1185 BODE RD M ❑Y El N SYSTEM❑UNK VEH. 0 ATCRASH 99-UUNKNOWN THER 9 16-TOP 3 INDistraction ALGN = r CITY PLATE NO. STATE YEAR F POINT OF 8 . El COM VEH 0 1 0 FIRST CONTACT 12 7_.; 6--:_.5 •Yves,See Sidebar U1 Z 1 FTRW08L61 KD72467 Unique Insurance ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same ILP3304656 1 Ei HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU L ❑Y ®N 2 0 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PEE 0 PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) )IT TOWED s Riemer-Jeffre W. 0 4 0 2 1 9 8 6 Ford F150 2021 00-NONE 1t i'_1 DUE TO CRASH ❑ ® 2 —I NAME(LAST,FIRST,M) y- mo day yr ©, C v 13-UNDER CARRIAGE 10� fj Y FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X E. (2]2405 ALISON AVE M ❑Y N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i• ! 4 COM VEH ❑ ® U1 1— FIRST CONTACT 6 7-r-_1 1_5 •If Yes,See Sidebar C PINGREE GROVE IL 60140 0 JWJR2-BD IL 2025 0 ln D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)962-1562 R560-4398-6095 IL D 0 1 FTEW1 EP1 MFC45196 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 1369984-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER Same u1 = (UNIT) I SEAT) /DOB) (SEX, (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS BWITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) - 1 3 08 /07/2008 M 2 4 0 1 Bryan Garcia/1185 BODE RD.ELGIN,IL,60120 996 1— (630)532-8625 U2 m / / #OCCS D / / u1 2 m / 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 10,05 /2024 04 07 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: u1 5 C) T 2 ❑ 28 03 ! I 0 PM ElConstruction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance uz Q ARREST NAME Garcia,Jesus,J. 11-601 51507000322 / / ❑PM SLMT ® 11 1 ❑Utility p UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N 0 ❑ SECTION CITATION NO. AM 30 I 2 ❑ 11 1 ARREST NAME 10/05 /2024 04 49 ®PM 0 Unknown work zone type Ut T 2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? El Y 30 1507-Ruiz.Alondra 301 246-Kite 11 , 12/2024 01 30 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 w ' 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 placarding(example placards will be displayed on the vehicle) 11 • CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - 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 • . 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 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 Beige Silver - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE