HomeMy WebLinkAbout2024-00064326 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I Ill
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III 10011011 lIOfl IHO MIII 111100110111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003519a92-
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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 1
El NOT ON SVEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) [Z] B Injury and JorTow Due To Crash YR 2024I2024-00064326 VENT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11
BOWES RD ® ❑
Elgin RELATED ®Y ❑N 10 08 2024 06'43 ❑AM ❑YES ®No U1 • .<
PRIVATE mo /day I yr ®PM FLOW CONDITION m
FT/MI N E S W AN NAN DALE
) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0
tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑ECUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
y
FOR DAMAGEDAREA(S) FRONT TOWED Ut 0
anna, M. 0 6 / 1 1 J 1 9 9 8 Volkswagen Jetta 2013 00-NONE ®i 1$ , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE ( L 2 FIRE ❑ ® 2 <
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 ® U2 m
281 SAN D H U RST LN F / ❑Y ESYlM El LINK VEH. O AT CRASH D 0 99-UUTHER NKNOWN O9 16-TOP ,Distraction Value ALGN =
r CITY PLATE NO. STATE YEAR POINT OF OIL 6 li COM VEH 0 ® 1 C)
3VWDP7AJ3DM401071 State Farm ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
a 99 9 Elinger.Jodi 0460245-SFR-13 1
I—
t
HOSPITAL(TAKEN TO) INCIDENT IF
'Y'
OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
o RESPONDER 281 SAN DH U RST.South Elgin. IL.60177 (630)666-4464 VEHU G1
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUM ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m
m / J FOR DAMAGED AREA(S) FRONT TOWED
NAME(LAST,FIRST,M) Y N
s Trinidad millan,Jose, D. 0 5 2 4 1 9 9 7 Mazda MAZDAS 2006 00-NONE
t3-UNDERCARRIAGE O' �'D1 DUE TO CRASH (ffi 0
, 2
, Qfj, FIRE ❑ [2] U2
mo day yr 10
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 C
DISTRACTED 0 ® SPDR C)
SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X
❑Y ®428 NORTH AVE M N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF NTACT 1 T_II a 1_6 C•IOMe6VEH SeeSideba❑ ® U1 to
~ C
60174 0 EU46532 IL 2024 REARf 0
Sn
n TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
(312)785-5943 99 UNK Other J M 1 CR293460122882 Kemper ❑y ®N RDEF
EMS AGENCY PE DV PPA ' PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Same 12RA000022255 Bnc , 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RElEl Y IXI N
l Same Ut _
(UNITE (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
I I U2 996 1-
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/ - #OCCS ' D
/ /• U1 1 m
I I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z
N 23 11 1 10,08 /2024 06 43 ®pm in a Work Zone? ®N DIRP co
I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 4 C)
T 2 0 23 99
! / 0 PM El Construction *
N 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME AM Maintenance uz 7
❑
Q CO 11 1 ARREST NAME Dexter. Breyanna, M. 11-904-B 1528-000151 / / ❑PM SLMT
o U CITATIONS ISSUED PENDING •
ROAD CLEARANCE TIME 0 Utility
o N SECTION CITATION NO. AM 45
T
2 0 ARREST NAME 10/08 /2024 07 40 ®PM 0 Unknown work zone type Ut
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1528-Rivera. Kevin 702 334-Fries 11 126/2024 01 30 0 PM Workers present? ®N U2 45
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
_� } A CMV is defined as any motor vehicle used to transport passengers or property and.
Tx
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
r I I I combination) or —I
lici I
INDICATE NORTH XI
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I -` ` r r r (example'.shuttle or charter bus)-or n
i_-----;-----% I t } t transporting employeeslin the courseaof theiremployment(example�emaployeerier O�3. I s
} trans
transporter-usually a van type vehicle or passenger car).or w
i.____A____: : , ?AI : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N
I ) ) for direct compensation(example:large van used for specific purpose).or
_ i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 11
placarding(example placards will be displayed on the vehicle) 71
I CARRIER NAME
Not To Scale t ADDRESSTo
Arransr?a I 0
• CITY/STATE/ZIP 0
MOTOR CARR ID ❑ Interstate ❑ Intrastate
- 0 Not in Comm./Govt. ElNot in Comm./Other Q
USDOT NO. ILCC NO.
C
, Source of above Z
❑ Yes 0 No ❑ Unknown A
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
Red Black
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑,r 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 X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
DUE TO ❑ Redmons/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE