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HomeMy WebLinkAbout2024-00065194 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III 'III IIII lull 11111111111111111 IIIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035a9350- u, 9 uz 1 1 1 1 U1 6 U2 U199 U2 1 U1 99 U2 1 4 9 U, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00065194 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT N PORTER ST ® ❑ In RELATED ❑Y co" 10 12 2024 04:15 ®AM ® ❑YES NO U1 -< g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®" DOORING ❑Y #OF MOTOR CI SLOW 2 U) ❑ FT/MI N E S W 'WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y ElN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EOUES 0(WV ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 / 2 0 /1 9 9 6 FOR DAMAGED AREA(S) FRONT TOWED Ut MUNIZ.JUAN. M. Honda Odyssey 2006 00-NONE 11 1 DUETO CRASH ❑ 21 NAME(LAST,FIRST,M) mo day yr 12 13-UNDERCARRIAGE 10)• ; 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 U2 2 ® m 465 FREMONT ST M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = ❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN CITY PLATE NO. STATE YEAR POINT OF 6 1� 6 1 4 COM VEH ❑ ® 1 n m jL FIRST CONTACT 12 7_-, �_6 "Irves,See Sidebar Ut 0 Z Unknown ❑Y ❑N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Briseno-Muniz.Juan- M. Unkown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER L RESPONDER 465 FREMONT ST. ELGIN - IL.60120 (224)605-5825 VEHU 0 0 DRIVER ® PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 99 m m / / FOR DAMAGED AREA(S) f720 4T TOWED Y N n mo day yr Ford F150 2011 00-NONE 11 12 , 173 NAME(LAST,FIRST,M) DUE TO CRASH ❑ ® 2 a 13-UNDER CARRIAGE 10 j Ij s FIRE El El U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 X ❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN 4 •Oistracton Value U1 9 H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RI ST CONTACT F 8 O7 tl m., .5 CUOM VEH Sideba❑ ® to r2240428B IL 2024 " 9 cn E M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTFW1 R63BFA49571 Safeway insurance company ®Y 0 N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I cordova-corona. Francisco. M. 3985391ilpp002 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 0N 125 N PORTER ST. ELGIN . IL.60120 (224)265-2011 U1 = (UNIT) 'SEAT) (DOB) 'SEX) ISAFT) (AIR) (INJ' (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'/(ADDRESS)+'TELEPHONE' (EMS) (HOSPITAL) W 06 /04/1976 M FRANCISCO M A CORDOVA-CORONA/125 N PORTER ST -ELGIN,8_60120/ U2 996 r (224)265-2011 _ m / / #OCCS D • / / U1• 1 m Ito I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 18 1 10/12 /2024 04 19 ❑pM in a Work Zone? El 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 5 C) T 2 Cl 18 1 05 28 1 / ❑PM p Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 p AM p Maintenance U2 • ® 11 1 ARREST NAME BRISENO-MUNIZ.JUAN. M. 11-601 1539000009 / / p PM SLMT o U .161 CITATIONS ISSUED El PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME E]Utility AM I 2 ElARREST NAME BRISENO-MUNIZ.JUAN. M. 11-709-A 1539000008 r / Bppl El Unknown work zone type U1 30 2 2 3 El • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? El Y 30 1539-Vargas, Miguel 300 - 11 ( 18/2024 09 00 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS r_.._r____.; 1 ; _I � } A CMV is defined as any motor vehxae used to transport passengers or property and. D A1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer r 1 { ; Al I combination) or �I INDICATE NORTH u BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` I I d i f -` ` r r r (example'.shuttle or charter bus)-or 0 designed to carry 15 passengerspoomnex a � ac carrier 0 `- -`- -- i Not To Sue I_I t i transporting employeesi the courseof their (example employee M transporter-usually a van type vehicle or passenger car).or 03 i-____ ____: : , I \` \ 'MI i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C %,` \ 1267N for direct compensation(example:large van used for specific purpose).or O , • L____ ____; , 2 ` P°rartss i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires in m il ',. placarding(example placards will be displayed on the vehicle) II CARRIER NAME ' it "—i1111j r' L ADDRESS 0 I I N ' o I I�.1 CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate I 0 Not mComm./Gout. Not mComm/Other r---- ----, , r USDOT NO. ILCC NO. m , Source of above Z . 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% 0❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No C Z Form Number D m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Gold White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE