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HomeMy WebLinkAbout2024-00065945 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets liii Ill DIII III Ifi IIIIIII II 11111111111111111 IIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003539326 u, 1 U2 1 2 1 1 U1 5 U2 1 U, 1 U2 1 U1 1 U2 1 1 10 Ut 4 U2 4 *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-$1.500 ®ON SCENE • 15 0 NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00065945 VENT ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT S RANDALL RD ® ❑ Elgin RELATED ®Y ❑N 10 15 2024 04:50 ❑AM ❑YES ®No u1 -< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W SPARTAN ) Kane HIT&RUN 0 Y CZN PEDALCYCUST®N ® FREE FLOW # LNS ' 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 8 / 3 0 /2 0 0 5 FOR DAMAGEDAREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) , Daniella. R. mo day yr Ford Ranger 2002 0-NONE 11 21 is , DUE TO CRASH 0 13-UNDER CARRIAGE �0 1 2 FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 936 MAR I O LN F ❑Y ESYlM❑UNK VEH. 0 AT CRASH 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I� 4 COM VEH 0 ® 1 0 ~ 1FTZR45E02PB38219 state farm ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 41 Gavina- Benjamin 3013034sfp 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER L RESPONDER 2100 NORTH AVE.ARLINGTON . IL.61312 (224)325-9308 VEHU 0 ®DRIVER ❑ PARKED 0 ORNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 • m m / l6 / FOR DAMAGED AREA(S) FROM TTOiETODCRASH Y N NAME(LAST,FIRST,M) Ramos.Yvony Jane_G. 0mo d 1 9 9 1 Mazda CX5 2019 00-NONE 1t r 12 1 ay yr ❑ ® 273 13-UNDER CARRIAGE 10 j ! 2 FIRE 0 ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR I C) a 3017 REMINGTON BLVD F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y MIN DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T CONTACTOF 6 7 iI Dli •s COM VEH 0 ® U1 F. O O'If Yes,See Sidebar C Z St Charles MO 63303 0 XJ1 FOX MO 2024 RFC 0 I;p M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (954)595-9501 050A292008 MO D 0 JM3KFACM1 K1602857 STATE FARM ❑Y ®N RDEF EMS AGENCY PE DV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 5996998C1825B001 Bnc , 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER E Same Ut _ (UNIT) (SEAT) (DOB) ISEXI (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I - uz 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 0 Y U2 Z N ® 11 1 10/15 /2024 05 19 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AMU1 1 2 0 2 23 ! , 0 PM ❑Construction * N 1 3 0 izi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 Q ARREST NAME Gavina. Daniella. R. 11-601 W1519-000195 / / ❑PM SLMT ® 11 1 0 Utility p U CITATIONS ISSUEDPENDING ROAD CLEARANCE TIME o N ❑ 0 SECTION CITATION NO. AM 50 T 2 0 ARREST NAME 10/15 /2024 05 35 ®PM 0 Unknown work zone type Ut OFFICER ID SIGNATURE BEAT/DIST. • SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 50 1519-Bae2a.Guadalupe 702 334-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 ; _r } 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 combination)or —I r ; ', ', CaarvRd r INDICATE NORTH X1 I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i ', 1 i I -` ` r r r (example'.shuttle or charter bus)-or n tV X r Not'Po Scab 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----;-----� -! . 1. - t transporting employees in the course of their employment(example.employee M k el : transporter-usually a van type vehicle or passenger car).or w �____A____: : , M DOfl'1°� I. 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____ ____; ; ; , — : 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires I placarding(example placards will be displayed on the vehicle) 11 XI CARRIER NAME Z ' I ADDRESS 0 I fn '• CITY/STATE/ZIP 0 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 . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No PJ 7) 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 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 X1 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m CJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Gray Gray - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 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