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HomeMy WebLinkAbout2024-00063494 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 1111111 010 III )III IIIIIII II 1111111111111111101101010 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003579927' u, 9 uz 1 1 1 1 ut 99 uz 1 U199 U2 1 U1 99 U2 1 4 11 u1 1 uz 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 EI NOT ON SVEHICLE/PROPERTY ill OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash yR 202412024-00063494 VENT ' ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg -r1 N SPARTAN DR ® ❑ Elgin RELATED ❑Y co" 10 05 2024 00:19 ®AM ❑YES ®No ut -•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m E15D ®I MI 0 E S W North Randall ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 D4 ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES 0 NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n FOR DAMAGEDAREA(S) FNT TOWED U1 O NAME(LAST,FIRST,M) .0. mo / day / RO yr Subaru Impreza 2003 00-NONE „ O_ z D, DUE TO CRASH ❑El 13-UNDERCARRIAGE to 1 FIRE IA 04 < SEX SAFT AIR AUTOMATION LEVEL LEVEL (�- 9 16-TOP®TOTAL(ALL) SYSTEM IN ENGAGED t OTHER DISTRACTED ❑ l U2 m M ❑Y ❑N ®UNK VEH. 9 AT CRASH 9 99-UNKNOWN 'Distraction Value g ALGN r CITY PLATE NO. STATE YEAR POINT OF 8 6 I 4 COM VEH 0 El 1 n F FIRST CONTACT 12 T l 5 'li Yes,See Sidebar U1 0 .e J F1 G D29663G508559 State Farm Insurance ®Y ❑N U2 1.1 I— m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Y Sosa,Javier 3355333-SFP-13 1 m I— o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o GI RESPONDER y°®EN 1113 RED BARN LN - ELGIN . 11_60123 (847)504-6203 VEHU GI ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 99 m m / 1 J FOR DAMAGED AREA(S) FROM TOWED Y N NAME(LAST,FIRST,M) lmo day 1 9 9 5 Jeep �Mpass 2017 00-NONE 13-UNDER CARRIAGE(after 19 y DUE TO CRASH ❑ ® 2 Guzman Rivas, Maria.G. �c) 12 ;_Z FIRE ❑ ® U2 C v c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a 301 DAWN CT C F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 1 0 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 7 Q,II 6 1,S COM VEH 0 ® U1 to l 'If Yes,See Sidebar Bloomingdale IL 60108 0 ER40571 IL 2025 R 0 cn 2 TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)812-9378 G255-5479-5953 IL D 0 1C4NJCEA7HD157132 Magnum Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same I LP2818190 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER y°®N Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m /• - #OCCS ' D / /• U' 1 m / / 01 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 11 9 1 10/05 /2024 00 19 ❑pM in a Work Zone? ElN 1 DIRP co I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 T 2 ❑ 03 28 / I 0 PM ❑Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance uz Q 1 CO 11 1 ARREST NAME / / ❑PM SLMT o UCITATIONS ISSUED PENDING ROAD CLEARANCE TIME ' 0 Utility 0 ❑ SECTION CITATION NO. p N AM 45 1 2 ElARREST NAME 10/05 /2024 01 15 El RA0 Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 0 AM Workers present? El 45 1511-Ayala. Roberto 800 - I / p PM ®N U2 I 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 _i } A CMV is defined as any motor vehicle used to transport passengers or property a , and. Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer , r I I ; ; I combination) or INDICATE NORTHXI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. ', i 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 L____a__.... . ; m,ii. _i : } - i transporting employees in the course of their employment(example employee M Vtransporter-usually a van type vehicle or passenger car).or w _ : 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 Randal l7Rd ' , i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m i- — 4 4 1 0 ; :. ` placarding(example placards will be displayed on the vehicle) CARRIER NAME Z Not To Scale ADDRESS To • F CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm/Gout. Not in Comm!Other USDOT NO. ILCC NO. ril , Source of above Z • . —I Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No M 7) 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 Form Number 0 M 7a 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 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Blue White 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 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 2 TOWED BYJTO. DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE