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HomeMy WebLinkAbout2024-00066242 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill i III 100 lu ll 111111111111111111H1 11111 1111110 II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003590639- u, 1 U21 1 1 1 U, 9 U2 1 U, 1 U2 1 Ut 1 U2 1 4 12 U123 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066242 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 COOPER AVE ❑Elgin RELATED ❑Y coN 10 16 2024 07:19 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 0 'COUNTY PROPERTY ❑Y ®N DOORING ❑Y #OF MOTOR ❑SLOW 15 fA 0/MI N OE s w Dundee Ave 'WITH VEHICLES INVLD El STOPPED U2 —I AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 110 oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut O . L. 0 1 / 2 4 /1 9 6 5 Cadillac XTS 2021 00-NONE „ 12 i' , DUE TO CRASH p NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 11 I .r 2 FIRE 0 ISI 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 2 m 191 GREGORY M SEARS DR F THER ❑Y ®SYsNEM IN DUNK VEH. n AT CRASH ENGAGED O 99-UNKNOWN 9 16-TOP 3 "OislractlonValue 9 ALGN = T. CITY PLATE NO. STATE YEAR POINT OF 8 i� 4 O. VEH ❑ ® 1 O I- ✓ FIRST CONTACT 5 7 t 6 © "Ir Yes,See Sidebar U1 Z 1 GYKN DRS4MZ112432 Americas Insurance Agency ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same A1C J208447 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 G) 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 1 / J1 9FOR DAMAGED AREA(S) FRONT TOWED O CRasH 0 ® NAME(LAST,FIRST,M) Navarrete. Karen 0 mo day 8 2 Nissan Armada 2021 oo-NONE ,t' 12 ' , 2 -1 a 13-UNDER CARRIAGE 10 i I! 2 FIRE ❑ ® U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) a` 200 GRAND B LV D F SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 9 0 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN O 'Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIR POIST NT COONTACT 8 7. ii• 6 5 GIOMesVSeeSidebarEH ❑ ® U1 to H •ELGIN IL 60120 0 ATF7235 WI 2024 " 0 CC/) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (815)302-8061 N163-5008-2625 IL D 0 JN8AY2BB9M9790282 American Family ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 41046-79434-82 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 POND El N Same Ut = (UNITE I SEAT) ;DOB) (SEX) ,{SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS B WITNESS ONLY (NAME i,I ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 03 /1 9/2014 F 2 3 0� 1 0 Sofia Pulido/191 GREGORY M SEARS DR.Gilberts.IL.60136 Refused(847)650-7167 U2 996 m m 1 4 03 /2 4/2017 F 12 4 0 1 0 Avery Pulido/191 GREGORY M SEARS DR.Gilberts-IL-60136 Refused #occs y (847)650-7167 _ 2 7 07 /09/2022 F 9 3 0 1 0 Shirin Sephri/200 GRAND BLVD,ELGIN.IL.60120 Refused U1 3 m 0315)302-8061 _ 2 7 09 /24/2020 F 9 3 0 1 0 Bejan Sephri/200 GRAND BLVD-ELGIN-IL.60120 Refused 0 (815)302-8061 U2 4 Z EV MOST EVNT LOT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y N ® 11 1 10/16 ,2024 07 19 ®PM in a Work Zone? ®N DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 T 2 0 30 99 ! / 0 PM ElConstruction * N 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Lafata,Cindy. L. 11-1402-A 474000544 / / ❑PM SLMT o U ❑CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME , ❑Utility o N 8AM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 474-Jacobs.Tyler 2o1 334-Fries 11 , 12/2024 09 00 0 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 r- -r--- 4 , 4 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r • ; i 'r i- r r , , i r r INDICATE NORTH combination) or —I M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! i- L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or X ; I I ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------.-----• + + • : - 1 - 1 i } - i• transporting employees in the course of their employment(example.employee M 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 O , , MOTOR CARR ID ❑ Interstate ElIntrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r•---, r - DO ILCC NO. m U N XI , Source of above Z . GVVVR/GCWR ❑ <10,000 0 10,000-26,000 1=1 >26,000 Z Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard 0 4 digit UN NO. 1 digit Hazard class No M 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 ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 7a 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z ip Gray Blue.Dark - 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- 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE