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HomeMy WebLinkAbout2024-00063094 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III 1In ll 11111111111111111 101111 100110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003539550' u, 1 U21 1 1 1 U1 2 U2 1 U1 1 U2 1 U1 99 u2 99 1 12 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1,500El NOT ON S ®ON SCENE 1 VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00063094 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT ST CHARLES ST ❑Elgin RELATED ❑Y coN 10 03 2024 06:55 ®AM ❑YES ®NO U1 .‹ PRIVATE mo /day I yr ❑PM FLOW CONDITION m ,O(]pa O 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR ❑SLOW 2 fy1 I� ICJ/MI N E S W Hammond ) Cook HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NMV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FRONT TOWED Ut O Harris, Ethan. L. 1 0 / 2 1 J2 0 0 3 Ford Econoline E250 2014 00-NONE „ I 12 D DUETOCRASH ❑ NAME(LAST.FIRST,M) mo day yr 13-UNDER CARRIAGE 11 1 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) Q 2 < SYSTEM IN ENGAGED 15-OTHER 9 16-7 3 DISTRACTED ® 0 U2 m 209 W 3 R D ST M ❑Y ®N ❑UNK VEH. O AT CRASH O 99-UNKNOWN 'Distraction Value 9 ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF 8 1 j 6 O COM VEH ❑ ® 4 n c Z 1 FTNE2EW6EDA96345 Selective Insurance P. ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a ONYX ELECTRIC INC S2663887 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r L RESPONDER 3230 SYCAMORE RD 192, Dekalb- IL.60115 (815)992-9310 VEHU X 5 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) fi20 IT TOWED Y N NAME(LAST,FIRST,M) Aceituno Garcia- Luis,A. 01 day 1 9 8 2 Ford F350 2010 oo-NONE 12 y FIREETocRasH ❑❑ ® U2 2 xi C v 13-UNDER CARRIAGE o .?_z C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ❑ ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER p9 16-TOP 3 9 4 E: 1209 PERRSONS PKWY M ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NaSTATE YEAR POINT OF 6 II I, 4 COM VEH ❑ ® U1 ca I— FIRST CONTACT 11 7__- 6I. S •lives,See Sidebar Belvidere IL 61008 0 486179D IL 2025 REAR 4 Sn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)703-8546 A23552182005 DC L 0 1 FTWW3B52AEA14571 Allstate ❑y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 802472267 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < RESPONDER Same U1 = (UNIT) I SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/-(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 06 /28/1986 M 2 4 0 j 1 0 Eliud Romero Martinez/510 S MAIN ST 2.Belvidere,IL,61000 Refused(815)540-7094 _ U2 996 i- m 2 6 05 /03/2000 M 2 4 0 1 0 Cristian Reyes Martinez/1027 KEPPLER DR,Marengo-IL,60152 Refused #OCCS y (224)833-5448 _ X 2 4 06 /1 0/1995' M 2 4 0 1 0 Julio Mujica Ponce/4309 MAJESTIC CT,Rockford.IL.61109 Refused UI 1 m 1815)217-8675 D / I 4 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 11 1 10/03 /2024 07 00 ❑pM in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 5 a 2 0 2 28 ! I 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q ARREST NAME Wascher Harris, Ethan, L. 11-601-Ax W1525000332 / / ❑PM SLMT CO 11 1 0 Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N ❑ ❑ SECTION CITATION NO. AM 35 2 0 ARREST NAME 10/03 /2024 07 33 ®PM ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 1525-Nava,Oscar 401 404-Duffy / / ❑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_ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; 0 A CMV is defined as any motor vehicle used to transport passengers or property and. (_Hanunond?Ave 1 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer I combination) or 'I r r ' ; ' Not To Scale -' INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', d i — — — — — r -` ` r r r (example.shuttle or charter bus)-or n X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i_----.....---% i -i } - i transporting employees in the course of their employment(example.employee M -usually a van vehicle or passenger ______.....___: : , i i 4trIs ansporter ordesgnatedtotrransportbetween9and 15rpassengers,including the driver, for direct compensation(example:large van used for specific purpose).or O — 7 I y 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ' placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z ' !III _ ADDRESS N • a I (� �!�' CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate ElNot in Comm./Govt. ❑ Not in Comm./Other Q r , USDOT NO. ILCC NO. , Source of above 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 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 m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White White - 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