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HomeMy WebLinkAbout2024-00066565 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III DIII III Ifi Ill III 111111111111111111101111011111 fill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035E4 3 u, 1 U21 3 4 1 UI 7 U2 1 U1 1 U2 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066565 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 RT20 ®gin El ❑Y coN 10 18 2024 09:50 ®AM ❑YES ®No ut ,‹ PRIVATE mo /day I yr ❑PM FLOW CONDITION m 1 0 I MI N E s Bluff ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n FOR DAMAGED AREA(S) FROM TOWED Ut 0 0 1 / 1 3 J 1 9 8 0 Jeep(after 196�1 rokee 2017 00-NONE 11 I t DUE TO CRASH ❑ NAME(LAST,FIRST,M) . Irma. E. mo day yr 'Z 13-UNDERCARRIAGE (31 tol• I 2 FIRE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 m 125 OAK ST 2 F SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 I PLATE NO. STATE YEAR POINT OF e l COM VEH 0 0 1 0 1C4RJFAG5HC646423 Direct Auto ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR _ 99 Same PAIL001206628 1 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 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 2 / J FOR DAMAGED AREA(S) FRONT TOWED NAME(LAST,FIRST,M) Cass, Kathleen.A. 1 mo 3day 1 9 5 3 Nissan Versa 2018 00-NONE +c'•• 12 s ReoCRASH ❑❑ ® U2 2 C v t3-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPDR C) SYSTEM IN ENGAGED 15-OTHER 6-TOP 3 9 1 0 a` 2020 ROYAL BLVD F ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 i, 4 COM VEH 0 ® U1 toF, FIRST CONTACT 6 Q -,_.=5 •IfYes,See Sidebar C ELGIN IL 60123 0 AX41363 IL 2025 - 0 .n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)575-5914 C200-5015-3971 IL D 3N1 CN7APOJL868039 Farmers ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 Same 192030263 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RESPONDERY0 Same U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME))(ADDRESS)/ITELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m / - #OCCS D / /• U1 1 73 I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z N ® 11 1 10,18 /2024 09 54 ❑pM in a Work Zone? ®N DIRP co 1 I 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 ❑ 03 40 ! / 0 PM ElConstruction a N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑ ❑AM Maintenance uz 3 Q ® 11 1 ARREST NAME Gutierrez, Irma, E. 11-710-A W402000741 / / ❑PM SLMT o UI 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility o N 8 AM 30 2 ❑ ARREST NAME / / ppl Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 402-Free, Richard 401 272-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. ^ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ' } Z A CMV is defined as any motor vehicle used to transport passengers or property and r- -r- --n 1 1 r r r r 1 I . r 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer ' r 1- 1 ; i i- r r , i i INDICATE NORTH combination).or —I 71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ', ! ' ' 1 ', ' f ` 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 -----'-----• 1 I • : ' ' 1 1 1 i } - t transporting employees in the course of their employment(example.employee 71 transporter-usually a van type vehicle or passenger car).or w . i 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 ' 1' 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 2 ' t ADDRESS 0 N • CITY/STATE/ZIP 2 ^ MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not m Comm./Govt. ❑ Not m Comm./Other O G r-----.-----,1 1 r r r r r----, 4 r USDOT NO ILCC NO. ITI • , Source of above z . ❑ Yes 0 No ❑ Unknown p 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 cn LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ z TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. y Black Gray - 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