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HomeMy WebLinkAbout2024-00063695 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III (III IIIIIII II II 111111111111110111111111111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035:T:269 u, 1 U21 1 1 1 U1 8 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U1 3 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 S VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ElB Injury and/or Tow Due To Crash YR 2024I2024-00063695 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 PAGE AVE ❑ Elgin RELATED ®Y ❑N 10 06 2024 00:41 ®AM ® ❑YES NO ut ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m 5 COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR 0 SLOW 1 U) IX!- ®/MI N OE S W Dundee Ave 'WITH VEHICLES INVLD El STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER 0 PARKED 0 DRIVERLESS ❑ PEo O PEDAL ❑EOUES 0 NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 020 1 C) FOR DAMAGEDAREA(S) FRONT TOWED Ut NAME(LAST,FIRST,M) Garcia.Sergio mo Nissan Sentra 2019 00-NONE DUETOCRASH 1 ❑ / day J yr tt- 12 21 t3-UNDER CARRIAGE 10( I• ; 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 02 m SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 709 E JACKSON ST M ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 'Distraction Value 9 ALGN I CITY PLATE NO. STATE YEAR POINT OF ®fl 6 ii 4 COM VEH 0 ® 1 O ~ 3N1AB7AP9KY321789 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 99 SANCHEZ, MARITZA, R. 3088900SFP13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER > o RESPONDER y°®EN 709 E JACKSON ST. BELVIDERE. IL.61008 (331)223-5820 VEHU 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m m / 1 FOR DAMAGED AREA(S) FRONT T1. OWED WDCRASH Y N 5 NAME(LAST,FIRST,M) SIBRIAN-JOSE.A. 0 0 day 0J 1 9 5 9 Toyota RAV4 2007 00-NONE O' ,s Dt ❑ ® 2 13-UNDER CARRIAGE 1 2 FIRE ❑ 2) U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 19 _ DISTRACTED 0 ® SPOR C) SYSTEM IN 0 ENGAGED Q 15-OTHER 9 16-TOP 3 0 a` 1416 LARKIN CT M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN -Distraction Value to N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RPOIST INT OONTACT 1 T_II a l_5 F •CIOMes 3eeSidebaO C ® U1 H H ELGIN IL 60123 0 CD24719 IL 2025 I 0 (n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)362-5946 S165-4215-9010 IL 0 JTM BD33V2751 23687 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 Same 802528341 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Same U1 = (UNIT) (SEAT) (DOB) (SEX) )SAFT( (AIR) IINJI (EJCT( (EPTH( PASSENGERS&WITNESS ONLY (NAME'/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 3 01 /1 3/2000 F 2 3 0 1 0 Maritza Ramirez Sanchez/709 E JACKSON ST,BELVIDERE.IL,61008 Refused 996 1— (331)223-5820 U2 m / / #OCCS D / / U1 2XI m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 11 1 10,06 ,2024 00 41 ❑pM in a Work Zone? ®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 ❑ 06 99 ❑AM ! I ❑PM El Construction * c' 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 Ei AM ❑Maintenance U2 Q • ARREST NAME Hernandez Garcia.Sergio 11-801 51521000285 / / ❑PM SLMT 21 11 1 0 Utility p UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N 0 ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/06 /2024 01 20 El RA0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1521-Vega.Wendy 201 - / / El 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 F 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 A 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i ; i N ' ' INDICATE NORTH combination) or —I XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n ', ', i u -! ` r r r (example.shuttle or charter bus)-or X / f Not To Scala 1 3 Is designed to carry15 or fewer passengers and operated a contract carrier O ----.....--- { f } } t transporting employee in the course of their employment(example employee 0 �____A____: : i r i 4tra Is usedror designated to trra-usually a van nsport between 9 avehicle or nd 15carpassengers,including the driver, C i // for direct compensation(example:large van used for specific purpose).or O 11 L_____-____; u,,, i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires rn / placarding(example placards will be displayed on the vehicle) 71 / uw. ` T. / ® L CARRIER NAME Z / ADDRESS 0 N / CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other ' USDOT NO. ILCC NO. m XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No 73 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? 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 C Z Form Number 0 m X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver Silver - 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE