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HomeMy WebLinkAbout2024-00065820 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III I IIII lull 111111111111111110111111110111111 III DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035.35E4 u, 1 U2 17 4 1 ui 2 U2 u1 1 U2 u1 1 U2 16 1 1 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE • 3 El NOT ON S VEHICLE/PROPERTY ElOVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00065820 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 LARKIN AVE ® ❑ Elgin RELATED ❑Y coN 10 15 2024 06:03 ®AM ❑YES ®No u1 ,< PRIVATE mo /day/yr El PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl) ❑ FT/MI N E S W 'WITH VEHICLES INVLD El STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FRONT TOWED Ut 0 , Simon,A. 1 2 / 0 1 J 1 9 6 3 Dodge Durango 2005 0-NONE tt ' 12 , t DUE TO CRASH ❑ ❑ NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE 10) 2 FIRE • SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 m 4 TIMES SQUARE 112 M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN CITY PLATE NO. STATE YEAR POINT OF 6 1� 6 1 4 COM VEH ❑ ❑ 1 O 1D4HD38N15F528808 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn a Same 12AU001241026 2 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o f❑El YON❑l N 3 Same VEHU 73 0 DRIVER ❑ PARKED 0 DRNERLE55 x PEE ❑PEDAL ❑EQUES 0 WV 0 NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) V N U1 2 m m / J F R DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Adame-Antonio o lday 1 9 yr 9 Other Other �-NONE 11 112 i REE o CRASH O ® U2 99 C v 13-UNDER CARRIAGE .I : STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 IN SPDR 0 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 a` 443 HUBBARD AVE M ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN II 'Oistrachon Value 0 to N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRPOST CNT OONTACT 15 7_'1 81_5 CIfOMeeVSee sidebar ® U1 C ZELGIN IL 60123 B TEAR Cl) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (773)517-4912 A350-0007-9199 IL D N/A ❑y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 6 i 1 48 2 N/A BAG• $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < RESPDYO0N Ut I (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS B WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) I I - uz 996 1- m / / - #OGCS y / / U1 1 m / I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 12 1 10/15 /2024 06 03 ❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 7 — 2 0 2 28 ! / 0 PM ❑Construction * c' 3 0 izI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 Q •1 ® 12 1 ARREST NAME Sosa-Andrade,Simon,A. 11-1008 298001134 / / ❑PM SLMT o u ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility NAM 30 2 0 ARREST NAME Sosa-Andrade.Simon-A. 6-101-A 298001135 r / 8 pM ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 298-Lopez. Mirko 602 272-Bajak 11 , 18/2024 01 30 ®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------.-----• + + • : - -, 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 CO ' 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 . 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 m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Blue - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 0 TOWED BY/TO: SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 0 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE