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HomeMy WebLinkAbout2024-00065504 , l Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii Ill OIl III 1In ll 11111111111111111 lUll Ill UI 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593433 u, 1 U21 2 4 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 11 U2 7 *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 • 14 El NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00065504 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'F'I N LIBERTY ST ®gin El ❑y coN 10 13 2024 01'04 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W FREM�NT ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 5 / 0 5 /1 9 8 5 FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) ,Julian,A. mo day yr Toyota RAV4 1999 00-NONE 11 iO 0 DUETOCRASH ❑ 13-UNDER CARRIAGE FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1D 21 O DISTRACTED 0 El U2 0 m 4501 E I L-176 M SYTM❑Y INS ME ❑UNK VEH. 0 AT CRASH 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 5 ALGN I THER T. El PLATE NO. STATE YEAR POINT OF 8 i. 6 4 COM VEH ❑ ISl 1 C) FIRST CONTACT 1 7_ ? 5 •Yves,See Sidebar U1 Q Z JT3GP10V2X7053042 Kemper ®Y ❑N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Same 12A0001563535 1 I— t HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ®N 2 G) 5' ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m 2 / / FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Escobar, Martin Imo 1 aay 1 9 6 7 Jeep(after 19�)npass 2021 oo-NONE 1c 12 s DUE TO ❑❑ ® U2 2 C v yr 13-UNDER CARRIAGE I FIRE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C) a 212 RANDOLPH ST M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N El UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value tV CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ©j 4 COM VEH ❑ ® U1 to 1— FIRST CONTACT 7 tz_1-;=5 •UYes,See Sidebar Z Waterloo IA 50701 0 MWY262 IA 2024 I 0 (Cn TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (319)290-1939 557YY0990 IA C 3C4NJDDB3MT571576 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 965665408 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 POND NI N Same U1 = (UNIT( i SEAT) iDOBi (SEX) )SAFTI (AIRI (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME i((ADDRESS)((TELEPHONE) (EMS (HOSPITAL) 2 3 02 /1 3/1966 F 2 4 0 1 0 Maria C. Escobar/212 RANDOLPH ST.Waterloo,IA,50701 996 1— (319)505-3090 , U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N 1 ® 1 1 4 10,13 /2024 01 18 ®pM in a Work Zone? El N DIRP co IN 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 ❑ 03 28 ! / 0 PM El Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 ARREST NAME Franco Macias,Julian,A. 3-707 1506-282 / / ❑PM SLMT 1 ® 11 4 ❑Utility p u 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 ❑ ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1506-Nunez, Maria 202 275-Engelke 11 / 12/2024 09 00 ❑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. r 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS 4 } A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i ; i r r , , i i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' ` i I ' t ` ` ` ., ' '. ' ' ` ` r r r (example'.shuttle or charter bus)-or n S ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----• + + • : - 1 - 1 i } - i• transporting employees in the course of their employment(example.employee ,3 transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi nated to trans rt between 9 and 15 assen ers including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP , , MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, r - DO ILCC NO. m U N XI , 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? O ❑ 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 — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to 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 Silver 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE