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HomeMy WebLinkAbout2024-00064051 , I Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii III OIH III 1III1011 lIOfl IH IIII��M1111 III DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY n035 93 3. u, 1 U21 2 4 1 U110 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 2 u2 4 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00064051 VENT ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 -PI ST CHARLES ST ® ❑ Elgin RELATED ®Y ❑N 10 07 2024 04_26 DAM ❑YES ®No U1 -< PRIVATE mo /day I yr 0 PM FLOW CONDITION m FT/MI N E S W DIXON AVE 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ®SLOW 1 U) ❑ 'WITH VEHICLES INVLD ❑ STOPPED U2 —1 ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRNER 0 PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL ❑EOUES 0 ARV ❑Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) O 6 / 3 O /1 9 6 6 FOR DAMAGEDAREA(S) FROM TOWED UI NAME(LAST,FIRST,M) GAVINA. MANUEL mo day yr Ford F150 2010 00-NONE 11 .i72., 1 DUETOCRASH p ® E 13-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 ® U2 0 m 111 S LIBERTY ST M PLATE NO. STATE YEAR POINT OF {I 6 it O COM VEH 0 El 2 O A ~ 1 FTFW1 EV7AFC66844 KEMPER ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 12RA000015913 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G) ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N s ABITUA,ALYCIA, I. 1 0 1 3 2 0 0 7 Toyota Camry 2007 00-NONE j'O ❑ ® 2 Xi , NAME(LAST,FIRST,M) mo day yr 10' Ojl 2 FIRE ❑ ® U2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPCA C) a` 862 ILLINOIS AVE F SYSTEM IN 0 ENGAGED Q 15-OTHER 9 76-TOP 3 9 0 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CONTACTNT O 11 7_ 11 6 5 COM VEH ❑ ® Ut C to F. 'If Yee,See Sidebar ELGIN IL 60120 0 A259411 IL 2025 REAR 0 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O (224)587-9366 ] A130-0090-7892 _IL D 0 4T1 BE46K67U012128 STATE FARM ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 GOMEZ. PETER 0389180-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 862 ILLINOIS AVE. ELGIN . IL.60120 (847)917-8377 Ut = (UNIT) I SEAT) (DOB) (SEX) ;SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAMEII(ADDRESS)7 i TELEPHONE( (EMS) (HOSPITAL) W 09 /04/1960 F ANDREA K VAN DER MOLEN/321 WING PARK BLVD _ELGIN.IL,60123/ 996 1— (630)485-8969- U2 m / / #OCCS D / /• UI 1 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 1 ® 1 1 4 10,07 /2024 04 26 ®pm in a Work Zone? ElN 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 1 C) T 2 0 04 18 ! I 0 PM 0 Construction * N 3 0 ®CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1 ® 11 4 ARREST NAME MORENO GAVINA. MANUEL 11-704-A 1542000001 / / ❑PM SLMT o uCITATIONS ISSUED PENDING ROAD CLEARANCE• TIME ❑Utility o N 0 ❑ SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/07 /2024 04 26 ®PM 0 Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1542-Chace. Ethan 401 334-Fries 11 , 19/2024 09 00 D ApM Workers present? ®N U2 30 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS } A CMV is defined as any motor vehxae used to transport passengers or property a, I and. Z 0 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer -< r Not To Scale � combination)or INDICATE NORTH .-0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 11 , i 1 -` ` r r r (example.shuttle or charter bus)-or C) X ICI._. f 0 ; 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 -- ... I i ,,,,J� } } t transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w C i-____A____: : . i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, rn _1 l® for direct compensation(example:large van used for specific purpose).or O L____ ____1 i; , I y ) i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 0 rn placarding(example placards will be displayed on the vehicle) 71 1 CARRIER NAME Z I ADDRESS N CITY/STATE/ZIP • I il :. ',. ... • • MOTOR CARR ID ❑ Interstate ❑ Intrastate • • ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q r , USDOT NO. ILCC NO. XI , • Source of above Z . MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No z Form Number 0 m 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 Black Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE ED ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO 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