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HomeMy WebLinkAbout2024-00066320 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIIIIII II 111111111111111111H1 11111 III Ill I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X003590632' u, 1 U21 2 4 1 UI 7 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 El NOT ON SVEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066320 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 BODE RD ® ❑ Elgin RELATED ®Y ❑N 10 17 2024 07:49 ®AM ❑YES ®NO U1 PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W SHALES ) PEDALCYCUST® ® 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 FOR DAMAGED AREA(S) RiONT_ TOWED U1 NAME(LAST,FIRST,M) mo day yr y 0 7 / 0 1 J 1 9 9 9 Toyota RAV4 2010 00-NONE DUE TO CRASH 0 "- All -' 13-UNDERCARRIAGE to I 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 4 < 528 WALNUT AVE 2 M ❑Y ISYNM 0 UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 iI 6 ii 4 COM VEH 0 ® 1 0 A ~ JTMZF4DV3AD019705 First Chicago Ins Co. ❑Y ix U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 1 99 9 Same iIs990684-00 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER❑ N3 Same VEHU ®DRIVER ElPARKED 0 DRNERLESS El PED ❑PEDAL El EQUES 0 NUN El NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED n NAME(LAST,FIRST,M) Rodriguez Gomez.Juan. F. mo 0 9 a 5Y 1 9 8 4 Ford Edge 2024 00-NONE io" 12 ' Z REocRasH p❑ ® Uz 2 C I', 13-UNDER CARRIAGE I STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR n SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a` 639 EDGEBROOK TER M ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j !-4 COM VEH ❑ ® U1 to F, FIRST CONTACT 6 7__•_1 ;_5 •If Yes.See Sidebar ELGIN IL 60120 0 EY29470 IL 2024 I 0 CC/1 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)802-2713 R362-4268-4273 IL B 7 2FMPK4G92RBA48398 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 Same 978012756 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER YO®N 3 Same u1 = (UNIT) 1 SEAT) (DOB' (SEX) ;SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME'7(ADDRESS)7(TELEPHONE' (EMS) (HOSPITAL) 2 4 02 /1 1 /2020 M 12 4 0 1 Jonathan Rodriguez Gomez/639 EDGEBROOK TER,ELGIN.IL.60120 U2 996 m m 2 3 06 /1 7/1990 F 2 4 0 1 Perla Rodriguez Gomez/639 EDGEBROOK TER-ELGIN-IL-60120 #OCCS D (847)802-2713 / / U1 1 m / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 10,17 /2024 07 49 ❑pM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 C) T 2 0 03 18 ! / 0 PM ❑Construction * cs 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 ARREST NAME Perez. Ronnie 11-710-A 324-(VII)1420 / / ❑PM SLMT 1 ® 11 4 0 Utility p u 0 CITATIONS ISSUED 0 PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME "'p NIIAM 35 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 324-Phillos.James 202 272-Bajak / / 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. r 0IF 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 r r INDICATE NORTH combination) or —I ."0 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 X ; 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 M transporter-usually a van type vehicle or passenger car).or w ' r i 4 Is used or desi Hated to trans rt between 9 and 15 assen ers including the dr ver, 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 ' t 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----, i - DO ILCC NO. m U N XI , Source of above Z . GVVVR/GCWR ❑ <10,000 0 10,000-26,000 0 >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 ❑ 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 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Gold WhiteEn - 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