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HomeMy WebLinkAbout2024-00063460 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill DIII III I IIII lull 11111111111111111111111111111111011III DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003532509 u, 1 U21 3 4 1 U1 7 U2 1 U, 1 U2 1 U1 1 U2 1 5 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 El NOT ON VEHICLE/PROPERTY in OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063460 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'IT N STATE ST ❑Elgin RELATED ❑Y coN 10 04 2024 07:11 ❑AM ❑YES ®NO U1 ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m qQ 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) IX!- 0/MI N E OS W Wing St 'WITH VEHICLES INVLD El STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑ORNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑SIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 1 0 / 0 8 /2 0 0 0 FOR DAMAGED AREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) ,Gladys mo day yr Lexus ES350 2020 Do-NONE 11 O� 1 DUETOCRASH ❑ DI 13-UNDERCARRIAGE 101 I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 4 m 923 JOHNSON CT F ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,OistractlonValue 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 1� 6 1 4 COM VEH ❑ ® 1 O A ~ 58AGZ1B12LU078278 Erie Insurance ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same Q040151262 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X o El Y El N 2 5 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 KW ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Caruso,Anna, M. 1 O / Oa /1 9 5 9 Volkswagen Jetta 2013 oo-NONEDA 13-UNDER CARRIAGE 11 I 12 2 REoCRASH ❑❑ ® U2 2 C v c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n E. 1302 SEBRING CIR F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 ❑Y ® 1 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8. ) i 4 COM VEH ❑ ® U1 CO H FIRST CONTACT 6 a_. , ws •If Yes See Sidebar C ELGIN IL 60120 0 EJ61515 IL 2025 iika M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)709-3883 C620-0535-9882 IL D 3VW2K7AJODM252785 Farmers Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 191682275 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < ERESPONDER Y0 lSame U1 = (UNITE i SEAT) i DOB) (SEX' ;SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'I-IADDRESS)+iTELEPHONEi EMS) (HOSPITAL) 1 3 08 /05/2001 M 2 3 0 1 Brayan J. Garcia-Ramirez/513 ELMWOOD DR,BELVIDERE,IL,61008 996 r (224)428-8381 , U2 m / / #OCCS D / / • u1 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z N i ® 11 1 10,41 /024 07 11 ®PM in a Work Zone? El DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM It YES check one below: U1 1 T 2 0 03 28 ! / 0 PM ElConstruction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q 1 CO 11 1 ARREST NAME Tapia Hernandez,Gladys 11-601-Ax 487000489 / / ❑PM SLMT o U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility p N AM 35 2 0 ARREST NAME Tapia Hernandez,Gladys 3-707 487000491 r / 8 ptil ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 35 487-Heal, Kayla 601 - 11 112/2024 01 30 ®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_ IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. Z ' I I 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r ; ' srmniat aJtJ I INDICATE NORTH combination) or -I JI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. ', i ~� r Nfir s 7`t -l' ` r r r (example.shuttle or charter bus)-or n X _� uunaast — —r 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 - — —` ® ® } (- i transporting employees in the course of their employment(example.employee M �-) 0 transporter-usually a van type vehicle or passenger car).or w ��wv p i r i 4 Is used or designated to transport between 9 and 15 passengers including the driver, C ( for direct compensation(example:large van used for specific purpose).or O L____L____; ; ; , r i 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 11 1 r ; placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' Not To Scale I I ADDRESS CITY/STATE/ZIP ^ MOTOR CARR ID ❑ Interstate El Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q ' I ^ USDOT NO. ILCC NO. C r , m , Source of above Z . If Yes Name on placard 0 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? 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 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 Blue Blue - 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