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HomeMy WebLinkAbout2024-00065967 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III Ifi IIII lull I11111111111111111 IIIIIIIIIIIIIIIIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003539325 u, 1 U21 2 4 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 4 11 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 2 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00065967 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I SPARTAN RD Elgin ID ❑Y co" 10 15 2024 06:34 DAM ❑YES ®No u1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m 1 DU 'COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR ❑SLOW 15 N ® ®/MI N E O W Duffy Dr WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS O tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nmi ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 / 1 6 J 2 0 0 4 FOR DAMAGEDAREA(S) FRONT TOWED Ut Rivera,Anairis Toyota Camry 00-NONE ®i 12 1 DUE TOCRASH ❑ M - 3 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 2 m 1130 YEW CT G F 2 SYTM 4 ❑Y ®SNE❑UNK VEH. O AT CRASHD 0 15-OTHER 99-UNKNOWN 9 6 16 TOP 3 4 •Distraction Value ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF 6 li COM VEH 0 ® 1 0 a 4T4BE46K79R095223 Progressive Ins Co ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Rivera,Yadira 980400344 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r a RESPONDER VEHU o Refused ❑Y ®N 1130 YEW CT G, ELG I N , IL.60120 (847)888-5100 2 0 U1 ®calves ❑ PARKED 0 cRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) m m / J FROM TOWED DAMAGED AREA(S) FRO TTLOiE EDCRasH Y N NAME(LAST,FIRST,M) Solis, Luis, E. 0 30 da0 7 yr 1 9 6 6 Jeep(after 19R&Jerokee 2014 00-NONE 1t' 12 1 ❑ ® 2Xi a 13-UNDER CARRIAGE 10 j ! 2 FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPCA n a 298 WINDSOR CT M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF E !I j /4�COM VEH ❑ ® U1 to I— FIRST CONTACT 5 7.r 6 '_OS •If yes,See Sidebar Z South Elgin IL 60177 0 1 0 AY48307 IL 2025 R 0 9C9) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)877-0143 S420-5256-6069 IL D 1C4PJLDS1 EW158098 State Farm Ins Co ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same J573188C1113A BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < Refused 0 YPONDER Same U1 = (UNIT) (SEAT) (DOB) (SEX) ISAFT) (AIR) IINJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME i/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 1 10 /1 6/1967 F 2 4 0 1 0 Solis Zepeda/298 WINDSOR CT A,South Elgin,IL,60177 996 1— (847)962-8967 - U2 m / / #OCCS y / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N 1 ® 11 1 10,15 /2024 06 34 ®pM in a Work Zone? ®N DIRP co 1 I 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 ❑ 28 99 ! / 0 PM ElConstruction * N 3 ❑ izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q • ARREST NAME Martinez Rivera,Anairis 11-601-Ax W481000214 / / ❑PM SLMT ® 11 1 ❑Utility p U CI CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? El 30 481-Rodriguez, Hannah 702 334-Fries , / El 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 ' } 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 '. ' 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----, ir - 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? 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 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 Black Silver - 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