HomeMy WebLinkAbout2024-00066062 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III
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III 1In ll 111111111111111111H1 11111 111111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003590636*
u, 1 uz 1 3 4 1 U1 3 u2 1 U199 U2 1 u1 99 U2 1 1 15 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 14
0 NOT ON
VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00066062 VENT *
ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT
SUMMIT ST ® ❑
Elgin RELATED ®Y ❑N 10 16 2024 08:12 ®AM ❑YES ®NO U1 .(
PRIVATE mo /day I yr ❑PM FLOW CONDITION m
FT/MI N E S W
) PEDALCYCUST CD ® FREE FLOW # LNS 0
tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 6 / 2 9 /1 9 8 6 FOR DAMAGEDAREA(S) HtCNT TOWED U1
NAME(LAST,FIRST,M) mo day yr
. PEDRO, R. Dodge Caravan(inc Grand)2009 00-NONE Q.iO.D1 DUEFIRE TO CRASH ® ❑
13-UNDER CARRIAGE ❑
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 ® U2 4 m
423 WALNUT DR M SYTM
❑Y ®SNE❑UNK VEH. O AT CRASHD 0 THER
99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
IN
CITY PLATE NO. STATE YEAR POINT OF 8 1 i+ 4 COM VEH 0 ® 1 O
FIRST CONTACT 12 7_ :{ 6_�5 ^Yves,See Sidebar 111 0
Z
2D8HN54109R515055 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 MEDIA, DELMY,A. 12AU001542093 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r
L RESPONDER 3 625 KEEP AVE, ELGIN . IL, 60120 (248)801-3620 VEHU 73
®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m
m / / FOR DAMAGED AREA(S) FRONT TOWED Y N
5 NAME(LAST,FIRST,M) Pizana Avila,Jennifer, F. 0 9 mo a 9 2 0 0 1 Hyundai Sonata 2012 00-NONE 11 0. 1O DUE TO CRASH 0 2 xi
13-UNDER CARRIAGE 10 z FIRE ❑ ® U2 C
c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR C)
SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3O 9 9 X
a` 360 VANDALIA ST F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value
to
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CNT ONTACT 2 7.F + 6 OS Clfve6M V See Sidebar EH ❑ ® U1
H ELGIN IL 60123 B CK79815 IL 2025 0 CCn
M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
P251-4260-1877 IL 0 SNPEC4AC4CH332155 NONE ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I
99 9 Rangel, Uriel, R. NONE BAG 3
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 <
RESPONDER
El PONI N 3 127 S LIBERTY ST. ELGIN , IL,60120 (224)256-0882 Ut =
(UNIT) I SEAT) i DOB) ISEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) iEMSt (HOSPITAL)
1 4 12 /09/2020 F 12 5 B 1 0 Aaliyah A. Mejia/625 KEEP AVE.ELGIN,IL,60120 Elgin Fire Provena St-Joseph U2 996 m
(248)801 3620 _ m
1 3 09 /07/2013 F 2 5 B 1 0 Kelley Calderon/423 WALNUT DR-Steamwood-IL-60107 Elgin Fire Provena St.Joseph #OCCS y
(847)637 6921 _ X
/ / — u1 3 m
/ I 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z
N 1 ® 1 1 4 10/16 ,2024 08 12 ❑pM in a Work Zone? ®N DIRP CO
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below:
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ®AM U1 3
2 0 25 99 10,16 ,2024 08 13 I-1 PM ElConstruction *
N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
Q 1 ® 11 1 ARREST NAME CALDERON. PEDRO, R. 11-305-A 51543-000005 10/16/2024 08 15 ❑PM SLMT
oN ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME AM' 0 Utility 35
2 0 ARREST NAME Pizana Avila-Jennifer, F. 3-707 S1543-000006 1 0,1 6 /2024 09 15 El RA0 Unknown work zone type U1
rY T
OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1543-Sturgeon. Kyle 201 272-Bajak 11 ,26/2024 01 30 0 pM Am Workers present? ®N U2 35
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.
D
1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer
, r 1 i ; combination) or 'I
INDICATE NORTH
14. X
I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver XI
} ', ', i -! ` r r r (example'.shuttle or charter bus)-or C)
i.----?-----. I r } i porting employeeslin the courseaof theirem and
operated
(example�emaployeerier
0
3 Is
Summlt?St } trans pay
transporter-usually a van type vehicle or passenger car) or pt
i_____A____4 : , i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, 73
MOM W11tn for direct compensation(example:large van used for specific purpose).or
O
L____ ____; ; ; , • _ y } i. 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
I _ placarding(example placards will be displayed on the vehicle) 3
rn
CARRIER NAME Z
0 ADDRESS 0
_ O
I •+ CITY/STATE/ZIP
I
Not To Scale - MOTOR CARR ID ❑ Interstate ❑ Intrastate
r ,
0 Not in Comm./Govt. Not in Comm./Other
USDOT NO. ILCC NO.
, 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? 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
XI
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
T
TRAILER 1 ❑ ❑ ❑ Z
-74
TRAILER 2 ❑ ❑ ❑ 0
U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z
Black Blue
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES
DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO:
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO:
DUE TO ❑ Redmons/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE