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HomeMy WebLinkAbout2024-00064050 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 010 III (III IIIIIII II II 1111111111111111111111110111111 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003532612- u, 1 U21 3 4 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U2 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 • 3 0 NOT ON SVEHICLE/PROPERTY in OVER$1.500 0 AMENDEDCENE(DESK REPORT) ElB Injury and JorTow Due To Crash YR 2024I2024-00064050 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I BLUFF CITY BLVD 1 ROUTE 20 HWY Elgin El ®Y ❑N 10 07 2024 04_29 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 0 /MI N E S W Route 20 ) Cook HIT 8 RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 D4 DRNER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGED AREA(S) FRONT TOWED U1 Dodge Ram 1500(pickup) 2013 00-NONE DUE TO CRASH NAME(LAST,FIRST,M) , Luis, F. mo day yr g 11_ al _1 ❑ 13-UNDERCARRIAGE �� DI I I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 4 m 7304 G RAN DV I EW CT M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF s {I� 4 COM VEH 0 ® 1 0 I— 3C63RRJL7DG591842 Allstate ❑Y ®N U2 m P. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 811090284 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU L El Y ®N 2 t7 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 7 / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Yen,Justine, B. 0 mo lday 1 9 4 9 Nissan Versa 2024 13-UNDE it; 12 : s REocRasH O 0 U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPUR 1) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X a` 4240N CLARENDON AVE F ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j ! 4 COM VEH ❑ ® U1 to FIRST CONTACT 6 7__•-_1 ;_5 •If Yes,See Sidebar C Z Chicago IL 606 0 FP268161 IL 2024 0 fp D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)815-0915 Y500-4224-9801 IL D 0 3N1 CN8EV1 RL899911 Progressive ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 971533901 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Y NR Same U1 = (UNIT( (SEAT) (DOBi (SEX) ;SAFT) (AIR) (INJ( (EJCT) (EPTH) PASSENGERS Si WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I / U2 996 1- m / - #OCCS D / /• U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N i ® 11 1 10/71 /024 04 29 ®pm in a Work Zone? ®N 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 03 99 ! / 0 PM ❑Construction * N 3 ❑ izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Gallardo, Luis, F. 11-601-Ax (W)455-390 / / ❑PM SLMT o UCITATIONS ISSUEDPENDING • ROAD CLEARANCE TIME ' 0 Utility o N 0 0 SECTION CITATION NO. AM 45 2 ❑ ARREST NAME 10/71 /024 04 29 ®PM 0 Unknown work zone type Ut r,f Co T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El Y 45 455 Hallas,Gabriel 401 334-Fries / p 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 .. _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r rI ; ' ' I I I I I rl. combination INDICATE NORTH ) or X1 RO"'m0 J i` ' ' BY ARROW 02 Is used or designed to transport more than 15 passengers including the driver C i I d i -` ` r r r (example.shuttle or charter bus)-or X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.-----;------t 4 i - -i } - i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_____A____: : , _ : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N [Tsr' ) I : for direct compensation(example:large van used for specific purpose).or O L____"-____; i , 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 1 I I I ` placarding(example placards will be displayed on the vehicle) 11 N CARRIER NAME Z I I ADDRESS. . . +1 0 II irrm Not To Scale ! CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above Z ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes 0 No ❑ Unknown A 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 73 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 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. y Black Gray - 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. 3 TOWED BY/TO: DUE TO ❑ © Redmons I Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE