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HomeMy WebLinkAbout2024-00066676 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III IIIIIII II 11111111111111111011liii 1111110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593 39* u, 1 uz 1 1 1 1 U1 7 U2 1 U111 U2 1 U1 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066676 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 LARKIN AVE ® ❑ Elgin RELATED ❑Y coN l O 18 2024 05:59 ❑AM ❑YES ®No U1 PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W N ) Kane HIT&RUN ❑Y ® N PEDALCYCUST®N [] FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW ❑Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O . Ruth. E. 1 0 / 0 9 J 1 9 4 4 Nissan Rogue 2018 00-NONE 11 NAME(LAST,FIRST,M) mo day yr 12 DUE 13-UNDERCARRIAGE 10l 2 FIRETO CRASH 0 Dg ❑ Ill SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El U2 2 m 325 N AIRLITE ST F ❑Y ISYNM❑UNK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 6 {I 6 ii 4 COM VEH 0 ® 1 0 a 5N1AT2MV9JC773557 Magnum ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR _ a Same ILP2810889 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER >. RESPONDER Same VEHU L ❑Y ❑N 2 G) ❑DRIVER ® PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑RUV ❑NCV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) V N U1 m m / / FOR DAMAGED AREA(S) fi20 4T TOWED n NAME(LAST,FIRST,M) mo day yr Cadillac Escalade 2007 00-NONE 11 12 ^_1 DUE TO CRASH 0 ® 273 13-UNDER CARRIAGE 10 j j s FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPOR 0 ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 UI 0 - — POINT OF 8 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH ❑ ® C FIRST CONTACT 7 0.l 6 :_5 •If Yes,See Sidebar EG57250 IL 2025 REAR 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 GYFK63817R152782 American Family ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Camacho. Lorymar 41090-20252-57 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER O N 870 LARKIN AVE. ELGIN . IL.60123 (224)388-7634 U1 = (UNIT) (SEAT) i DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)i{ADDRESS)/(TELEPHONE I (EMS> (HOSPITAL) W 1 2 /1 3/1997 M Juan Jose Soto/870 LARKIN AVE ,ELGIN,IL.60123/ 996 1— (224)605-4723 , U2 m / / #OCCS D / /• ut1 m I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 1 10/18 /2024 05 59 ®pm in a Work Zone? ®N 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 7 C) T 2 0 03 11 ! / 0 PM ElConstruction * c' 1 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 Q ® 11 1 ARREST NAME Tomasek. Ruth. E. 11-601 W1532000306 / / ❑PM SLMT o U 0 CITATIONS ISSUED 0 PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility o N 8AM 30 2 0 ARREST NAME r / ptit ❑Unknown work zone type U1 T • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMEEl Y2 2 3 0 1532-Hernandez. Daniel 601 - / / Q PM Am 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- -r--- 4 , 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 ' L ', ', ! i. 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 placarding(example placards will be displayed on the vehicle) 11 T. . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP O , , • . - MOTOR CARR ID ❑ Interstate El Intrastate ❑ 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 . 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 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z En Silver Beige - 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