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HomeMy WebLinkAbout2024-00066460 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III (III (IIIIII II 11111111111111111011110111 III I II I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0035.35 1 u, 1 U21 3 4 1 U1 3 U2 1 U, 1 U2 1 Ut 1 U2 1 4 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00066460 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'r'I N MCLEAN BLVD Elgin ❑ RELATED ®Y ❑N 10 17 2024 07:19 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W W ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 DI DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EouEs ❑NIN ❑NDV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0 0 7 / 2 0 /1 9 8 2 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) Perez,Cornelio mo day yr Kia Motors Colnrte 2016 00-NONE 11 12 D DUE TO CRASH ® ❑ 13-UNDERCARRIAGE FIRE ❑ fm SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1D O DISTRACTED 0 ® U2 2 m 42 WREN RD M ❑Y ®SYSNEM❑UNK VEH. O AT CRASH D 0 15-OTHER 99-UUNKNOWN 9 16-TOF� ,DistractionValue 9 ALGN - r CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii_ COM VEH 0 ® 1 (7 I— KNAFK5A87G5583621 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Y Rivera,Carmen 976153669 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o RESPONDERN 6840 JACK HORNER LN ,Jacksonville, FL,32210 (630)788-0035 VEHU GI ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EaSES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 GI m m FOR DAMAGED AREA(S) Fi20 IT TOWED Y N 5 NAME(LAST,FIRST,M) Banuelos. Madelia m0 7 / /0 day 0 6 1 9 yr 3 General MotorSitiaEp 2014 00-NONE Oar 12 y DUE TO CRASH ❑ ® 2XI v 13-UNDER CARRIAGE 101 ! 2 FIRE ❑ ® U2 C 7, STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) a` 604 ALICE PL F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CNT ONTACT 11 7_'1 8 115 C•IOMesVSee Sidebar ® U1 P. ELGIN IL 60123 0 1315410B IL 2025 I 0 CC/1 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)209-2190 B542-5447-3792 IL D 0 3GTU2VEC9EG218789 State Farm ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I Banuelos Avila.Octavio 0286729-SFP-13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 604 ALICE PL, ELGIN , IL,60123 (847)305-6300 U1 = (UNITE 1 SEAT) ;DOBi (SEX) (SAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(ADDRESS)/(TELEPHONE} (EMS' (HOSPITAL) 1 6 01 /01 /1950 M 2 3 0 1 0 Catalino Herrera Osto/42 WREN RD,60110 996 r (229)345-5537 , U2 m 1 3 07 /21 /1959 F 2 3 0 1 0 Angelina Perez/42 WREN RD.60110 #OCCS D (229)162-6733 _ X / / U1 3 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N ® 11 1 10/17 /2024 07 19 ®pm in a Work Zone? El N DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 C) T 2 0 25 28 ! I 0 PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance uz Q • ARREST NAME Herrera Perez.Cornelio 11-601 51538000004 / / ❑PM SLMT CO 11 1 0 Utility p U CITATIONS ISSUED PENDING ROAD CLEARANCE TIME o N SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/17 /2024 07 30 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1538-Estrada, Leticia 602 246-Kite 11 / 12/2024 01 30 ®PM Workers present? ®N U2 30 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. 0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I ADDITIONAL UNITS FORMS ' I ® } A CMV is defined as any motor vehicle used to transport passengers or property a, and. Z ( 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer _Not To Scale 1 combination) or r r ; ' I INDICATE NORTH XI I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J. J. ', i ®r I tI t r r r (example'shuttle or charter bus)-or 0 3. Is designed to carry15 or fewer passengers and operated contract carrier M- - ------ + y `I V1/71-11 l -t t } transporting employees in the course of thir employment(example employee transporter-usually a van type vehicle or passenger car) or CO i_____A____: : , : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N I ) — — — — — ( for direct compensation(example.large van used for specific purpose).or O L____�____; + — • Unit i } i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m v i;1 placarding(example placards will be displayed on the vehicle) 71 II, CARRIER NAME Z ADDRESS 0 • • CITY/STATE/ZIP 0 r , - MOTOR CARR ID ❑ Interstate ❑ Intrastate ( 0 Not in Comm./Govt. El Not in Comm./Other r- -'-- i I I -• • ^ USDOT NO. ILCC NO. m , Source of above Z . ❑ Yes 0 No ❑ Unknown 0 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 C Z Form Number D m 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m D TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z White Black 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 1 Impound Lot Garage 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