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HomeMy WebLinkAbout2024-00066595 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III )IIIIII II 111111111111 111110111 111011 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E421 u, 1 uz 1 3 4 1 U199 U2 1 U1 1 U2 1 U,99 u2 99 1 10 u1 4 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 14 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066595 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 'IT VILLA ST ❑Elgin RELATED ®Y ❑N 10 18 2024 12:02 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W NATIONAL ) Kane HIT&RUN ❑Y CZ " PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES 0 NIN ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N n FOR DAMAGED AREA(S) FRONT_ TOWED U1 NAME(LAST,FIRST,M) . M. mo day yr } 0 / J Dodge Caravan Inc Grand 2018 00-NONE DUE 11 (12 1 -1 ❑ 13-UNDERCARRIAGE 191• IDI 2 FIRE ❑ IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 0 m 470 ARLINGTON AVE F ❑Y ❑SYSNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 76-TOP 3 •Distraction Value 9 ALGN 2 CITY PLATE NO. STATE YEAR POINT OF 8 {I� 4 COM VEH 0 ® 5 0 A ~ 2C4RDGBG9JR222266 Nationwide Ins ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same 9112J 042949 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ❑" 2 0. 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EDUCE 0 WV ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m / J FOR DAMAGED AREA(S) FRONT TOWED , NAME(LAST,FIRST,M) Cortes. Maria. I. Imo 1 day 1 9 y8r 9 Toyota Tacoma 2016 00-NONE ;0 12 s FIREETocRasH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n a` 1659 ROSEHALL LN F SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 9 0 X ❑Y ❑ N ®UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i all! 4 COM VEH ❑ ® U1co F, FIRST CONTACT 6 7--_W;_S •If Yes.See Sidebar C ELGIN IL 60123 0 2186057B IL 2025 RFArt 0 C .11 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O (847)525-4980 C632-5498-9922 IL D 5TFCZ5AN6GX039459 All State Ins ❑y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 962998189 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RESPONDERY0 Same Ut = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) I I U2 996 1- m - '#OCCS > / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z N ® 11 1 10/18 /2024 12 02 ®pM in a Work Zone? ®N DIRP CO 1 I 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 28 03 ! / 0 PM ❑Construction * c' 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑ ❑AM Maintenance U2 3 • Q CO 11 1 ARREST NAME Cortes. Maria. I. 11-601-Ax 50430-000437 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8 AM 30 2 ❑ ARREST NAME / / ppl ❑Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 430 Nemtiev.Sergey 401 275 Engelke , ❑PM ®" 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----, , 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 ; i- r r , , i r r INDICATE NORTH combination) or —I r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' •_ ', ', ! i. ._ ' ' '. ', ' 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 m placarding(example placards will be displayed on the vehicle) .Z1 I. . ` CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP n , , MOTOR CARR ID ❑ Interstate ElIntrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r•---, - DO ILCC NO. m U N XI , Source of above Z . Were HAZMAT placards on vehicle? ❑ Yes ❑ No If Yes, Name on placard O 4 digit UN NO. 1 digit Hazard class No P3 73 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 g Did Carrier Safety Regulations MCS)violation contribute to the crash% A ❑ Yes No ❑ Unknown 0 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 0 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 Black RedEn - 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