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HomeMy WebLinkAbout2024-00065732 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III )III IIII lull I 4411111111111111111 IIIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035395 u, 1 uz 1 1 1 8 U1 2 u299 u1 1 U2 1 U1 99 U2 99 1 12 ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON SVEHICLE/PROPERTY ®OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00065732 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 RT20 WB El ❑ Elgin RELATED ❑Y coN 10 14 2024 04'Sl ❑AM ❑YES ®NO U1 ,‹ PRIVATE mo /day I yr ®PM FLOW CONDITION m ®1015/MI N E S® South State ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nmi ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 / 2 0 /1 9 7 0 FOR DAMAGEDAREA(S) FROM TOWED U1 NAME(LAST,FIRST,M) mo day yr , Ketan.S_ Toyota Corolla 2007 00-NONE 11 1 DUE TO CRASH ❑ Vi 12 ❑ 13-UNDER CARRIAGE t 2 FIRE 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED ® 0 U2 m 457 MOORESFIELD ST M ❑Y IN N SYSTEM❑UNK VEH. O AETCRASHD 0 99-UNKNOWN 15- THER 9 16-TOP 3 Distraction 9 ALGN = 11.' VIN PLATE NO. STATE YEAR POINT OF 8 116 I( COM VEH ❑ ® 1 n F FIRST CONTACT 10 7 71_1.__,.5 "If Yes,See Sidebar U1 0 Z 2T1 BR32E67C799596 American Family Insurance ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR _ THAKKAR. HEMANGINI, K. 410836837800 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER 457 MOORESFIELD ST. ELGIN - IL,60124 (814)232-6315 VEHU G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUV ❑NCV 0 Dv CIRCLE NUMBER(S) U1 r. DATE OF BIRTH MAKE MODEL YEAR 2 m 5 0 6 / 1 6 /1 9 6 7 FOR DAMAGED AREA(S) TOWED ODCRASH Y N NAME(LAST,FIRST,M) Escobar,Juan. M. mo day yr Ford F150 2024 oo-NONE 1t. 12_1. , ❑ ® 273 c 13-UNDER CARRIAGE 10 i Z FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ SPDR n SYSTEM VIN 6 ENGAGED 9 15-OTHER 9 16-TOP 3 9 4 E 3320 CHASE LN M ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN -OistractionValue N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COF ONTACT 1 7_Il a l_5 C•IOMe6 3eeSidebaH ❑ ® U1 to H ELGIN IL 60124 0 3943650B IL 2025 REARf 4 Cl)C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)652-3812 E216-4336-7171 IL D 0 1 FTVW3LK3RWG11797 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Escobar. Martin 0393164SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER pO®N 2650 W LAKE ST. Hanover Park, IL.60133 (847)652-3878 U1 = (UNIT) I SEAT) (DOB' (SEX) ISAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME'/(ADDRESS)7 iTELEPHONE) (EMS' (HOSPITAL) 1 3 02 /26/1972 F 2 4 0 1 0 HEMANGINI K. THAKKAR/457 MOORESFIELD ST.ELGIN.IL.60124 Refused 996 1 (814)232-6315 _ U2 m / / #OCCS D • / / u t 2 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ®Y U2 Z N ® 11 1 10/14 ,2024 04 52 ®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 7 C) T 2 0 28 04 ! / 0 PM ®Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 Ei AM ❑Maintenance U2 •Q ® 11 1 ARREST NAME Thakkar, Ketan,S. 11-601-Ax W1525000334 / / ❑PM SLMT o UCITATIONS ISSUEDPENDING • ROAD CLEARANCE TIME ❑Utility o N 0 0 SECTION CITATION NO. AM 45 2 0 ARREST NAME 10 7 1 4 /2024 05 45 ®PM 0 Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIMEY 45 2 2 3 0 1525-Nava.Oscar 701 - 7 / Q PM Workers present? ®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. Tx Has a weight rating more than 10,000 pounds(example truck or truck/trailer r 1 i i INDICATE NORTH combination) or —I XI ( N } ,,✓1 - W r BYARRO 2 Is used or designed to transport more than 15 passengers including the driver ', ', i /�u >Y' -! ` r r r (example'.shuttle or charter bus)-or CC Not To Scele_i �y� • 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 < ; stransporting employees g p (example� ployee M w.,,: / I. - t em to ees in the course of their employment .em / transporter-usually a van type vehicle or passenger car).or CO , t i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or O L____--____; i. r i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 4 11 placarding(example placards will be displayed on the vehicle) 71 — — CARRIER NAME Z —hrli2 .. ADDRESS 0 • CITY/STATE/ZIP 0 MOTOR CARR ID ❑ Interstate ❑ Intrastate r , 0 Not in Comm./Govt. El Not in Comm./Other 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? 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 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 m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Beige Red - 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