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HomeMy WebLinkAbout2024-00066642 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III (III IIIIIII II 11111111111111111011liii lID 1111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO35.3:34 u, 1 U21 3 4 1 U1 4 U2 1 U, 1 U2 1 Ut 1 U2 1 1 11 Ut 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00066642 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'F'I VILLA CT Elgin El ❑Y coN 10 18 2024 03:46 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 1 0/MI N E S W East Chicago ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N [] FREE FLOW # LNS 0 tg ORNER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EOUES 0 Nmi ❑r)cv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 4 / 2 4 /1 9 8 3 FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mD day yr General MotorSiiq 2007 00-NONE 11 O1 , DUE TO CRASH ❑ 13-UNDERCARRIAGE �0 21 I I 2 FIRE 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 I� U2 4 < 668 BLUFF CITY BLVD M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 1� 6 1 4 •COM VEH 0 ® 1 0 ~ 2GTEK13M071658758 Kemper ❑v ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Same 12AU000377745 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU L El Y El N 2 0 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) Fi20 IT TOWED Y N s 0 4 1 1 2 0 0 7 NAME(LAST,FIRST,M) Garcia. Hector-A. Mazda Miata MX5 1993 oo-NONE ) : 2 FIRE ❑ ® U2 C DUE TO CRASH ❑ ® 2 12 I v mo day yr ( ) 13-UNDER CARRIAGE c 10 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X a` 823 MAY ST 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 I— FIRST CONTACT 6 7__•-__;_S •If Yee See Sidebar ELG I N IL 60120 0 EW81846 IL 2025 l 0 CC11 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)245-6825 G620-3210-7104 IL D JM1 NA3516P0408518 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I PEREZ.ONEIDA 0195691-SFP-13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER POO NR 823 MAY ST. ELG I N - I L,60120 (224)388-6033 U1 = (UNIT( i SEAT) (DOB) (SEX) )SAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)r{ADDRESS)1(TELEPHONE) (EMS( (HOSPITAL) 2 3 1 2 /01 /2008 F 2 4 0 1 0 Alexa Garcia/823 MAY ST.ELGIN.IL.60120 996 r (224)247-4456 _ U2 m / / #OCCS D / / U1 1 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur ❑Y U2 Z N i ® 11 1 10/18 /2024 03 46 ®pm in a Work Zone? ElN 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 1 C) T 2 0 28 03 ! / 0 PM ElConstruction * N 3 0 iz1 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance uz Q CO 11 1 ARREST NAME Mora, Rolando 11-601-Ax W1534000080 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8 AM 30 2 0 ARREST NAME / / ptit ❑Unknown work zone type Ut T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1534-Santiago.Jorge 101 - / / ❑❑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. 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 • M BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! (- L ' ' '. ', ' 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------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 C r-----.-----, r r r r r•---, i - 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 PJ 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 Blue 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