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HomeMy WebLinkAbout2024-00064275 , I III ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets Il ii III 010 �1 1III101111000110 1111 III 111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003573a65t u, 1 u210 1 1 1 U1 9 U2 1 ut 1 U213 Ut 1 U2 1 1 9 Ut 23 U221 *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 [23 NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00064275 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 LARKIN AVE ❑ Elgin RELATED ❑Y coN 10 08 2024 03:05 ❑AM ® ❑YES NO ut ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY -.Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I ElAT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EOUES 0 NIA/ ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 1 / 2 8 /2 O 0 6 FOR DAMAGED AREA(S) FRONT TOWED U, NAME(LAST,FIRST,M) .XAVIER,J. mo day yr Nissan Altima 2011 00-NONE 13-UNDER CARRIAGE 11 .i72 , DUE TO CRASH ❑ 21 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) t9 O DISTRACTED 0 53 U2 2 m 1402 TODD FARM DR M PLATE NO. STATE YEAR POINT OF {I 6 p O COM VEH 0 ® 1 O 1 N4AL2AP7BN42711 1 First Chicago ❑Y ®N U2 m P. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Y ROBLEDO,XAVIER ILS 827631-03 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER 1402 TODD FARM DR. ELGIN . IL.60123 (224)402-2880 VEHU G1 ❑DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 KW ❑NOV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) mo day yr Mazda 3 2014 00-NONE 11 ` 12 , y DUE TO CRASH ❑ ® 1 c 13-UNDER CARRIAGE 10 I 1 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPDR 0 ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value U1 0 - 6 1I ll 4 COM VEH ❑ ® to H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7 Q� 6 5 Irvee,See Sidebar CJ76933 IL 2024 1 0 CCn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JM1 BM1 U7XE1 197531 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Romero-Arceo. Karyn. M. 2781941SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1915 CASTLE PINES CI R. ELGIN . IL.60123 (630)673-1452 Ut = (UNIT) I SEAT) (DOB) (SEX) i)SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)1(TELEPHONE} (EMS) (HOSPITAL) 1 6 01 /29/2008 F 2 4 0 1 Laila Czerwinski/583 OWASCO AVE,ELGIN.IL-60123 U2 996 m m 1 4 09 /08/2008 2 4 0 1 Xavier J. Roiledo/1402 TODD FARM DR-ELGIN,IL,60123 #OCCS D (847)450-3322 _ X 1 3 09 /07/2001 M 2 3 0 1 Victor A. Salas/1107W HIGHLAND AVE.ELGIN.IL.60123 Ut 4 m (630)823-1339 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z N ® 18 5 10,08 /2024 03 30 0 pm in a Work Zone? El DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 C) T 2 0 30 26 ! / 0 PM El Construction * N 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance uz 7 Q 1 CO 11 5 ARREST NAME / / 0 PM< ❑Utility SLMT 0 U 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8AM 10 2 0 ARREST NAME / I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 537-Sanders, Richard 602 - ( / ❑❑PM Workers present? ®N U2 10 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 ' ` i '. ' t ` ` ` ' ' '. ' ' ` ` 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------.-----• + + • : - -, 1 - 1 i } } i• transporting employees in the course of their employment(example employee 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 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , . - MOTOR CARR ID ❑ Interstate El intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, i - DO ILCC NO. m U N XI , Source of above Z • . 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? 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 T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Gray Red - 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