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HomeMy WebLinkAbout2024-00066064 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 111111111111111111H1 110101111 111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003590626 u, 1 U21 1 1 1 U116 U2 1 Ut 1 U2 1 U1 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$507-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00066064 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 MARK AVE ® ❑ Elgin RELATED ❑Y coN 10 16 2024 08_26 ®AM ❑YES ®NO U1 PRIVATE mo /day I yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 15 N 050 0/MI N 0 S w RUTH Dr 'WITH VEHICLES INVLD ❑ STOPPED U2 —I AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRONT TOWED Ut O , E. 0 3 / 1 8 J 1 9 9 3 Chevrolet Equinox 2011 00-NONE ®i ©I , DUE TO CRASH p DI - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE t9 I 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 1940 MARK AVE 17 M ❑Y ESYlM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 ){ 6 li COM VEH 0 El 1 0 a ~ 2CNALBEC7B6476679 STATE FARM ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same 1894211SFP13 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L ❑Y ❑N 2 0®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) PEREZ GOMEZ. KIMBERLY,Y. 03 o ld y0 1 yr 9 9 6 Dodge Nitro 2009 00-NONE +c' 12 s FIREETocRasH O 0 U2 2 C c 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPOR C) E 1640 MARK AVE a F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y El N UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j Ir.4 COM VEH ❑ ® U1 8 to F„ FIRST CONTACT 6 7_ .__.5 •It Yes,See Sidebar C ELGIN IL 60123 0 DC89840 IL 2025 _ 0 Cn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)219-5588 NONE IL Other 0 1D8GT58K59W529478 FIRST CHICAGO INSURANCE C ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I PEREZ.WILLIAM, D. ILS103721300 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1640 MARK AVE a, ELGIN , IL,60123 (773)441-6009 U1 = (UNIT/ ;SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONEI (EMS( (HOSPITAL) 2 4 02 /01 /2024 F 13 4 0 1 O YOHANDRI GOMEZ/1640 MARK AVE,ELGIN,IL,60123 996 r (224)219-5588 , U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N ® 11 1 10/16 (2024 08 26 ❑pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ID AM It YES check one below: U1 3 C) T 2 0 28 99 ! , 0 PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 z ❑AM 0 Maintenance U2 CO 11 1 ARREST NAME NOOR. MAH. E. 11-601 w244-1784 / / El PM SLMT o U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility M I 2 0 ARREST NAME PEREZ GOMEZ. KIMBERLY,Y. 6-101 244-1785 r / 8 pM El Unknown work zone type Ut 3O T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME El Y 30 244-Blomberg, Michael 502 272-Bajak / , ❑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 is defi as any motor vehicle used to transport passengers or proty and. Z r-"--r----, , 1 r r r r r , , , 1 . r 1 HasCMV a weightned rating more than 10,000 pounds(example.truck or truckrtra periler -< ' r 1 ; i i i- r r , , i i combination).or INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', ' t ` ` ' ' 1I. ` r r r (example'.shuttle or charter bus)-or n S 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----'-----• I + • : .- " 1 1 1 i } - i- transporting employees in the course of their employment(example.employee ,3 ' I transporter-usually a van type vehicle or passenger car).or 03 ' r i• 4 Is used or designated to transport between 9 and 15 passengers,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) 71 M CARRIER NAME Z ' .. ADDRESS 0 N . O CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ElNot in Comm./Gout. ❑ Not in Comm./Other Q • C r-----.-----, r r r r r•---, r - DO ILCC NO. m U N XI , • Source of above Z . 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 m TRAILER 1 ❑ ❑ ❑ z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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