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HomeMy WebLinkAbout2024-00066760 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III I IIIIIII II 11111111111111111011III 11101111 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593:50 u, 1 U2 1 3 4 1 U1 5 U2 1 U, 1 U2 1 Ut 1 U2 1 1 10 Ut 3 U2 7 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 El NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066760 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1'I SHALES PKWY ®gin ID ®Y ❑N 10 19 2024 08:05 ®AM El ®No u1 • ,< PRIVATE mo /day I yr ❑PM FLOW CONDITION m FT/MI N E S W RTZO 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) ❑ Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS ' 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL 0 EOUES 0 NW ❑NCv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) V N 4 0 0 4 / 2 2 /2 0 0 1 FOR DAMAGEDAREA(S) FRONT TOWED Ut NAME(LAST,FIRST,M) mo day yr Nissan Sentra 2019 00-NONE 11 12 DUE TO CRASH 0 21 13-UNDER CARRIAGE 10 2 FIRE ❑ Ill SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 53 U2 4 m 9N900 KOSHARE CIR F ❑Y ®SYSNEM❑UNK VEH. O AT CRASH D 0 99-UUTHER 9 NKNOWN 8 16 TOP 34 'Distraction Value 9 ALGN = r CITY PLATE NO. STATE YEAR POINT OF {I 6 i(_ COM VEH 0 ® 1 0 a 3N 1 AB7AP3KY457027 AAA ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Valle_Telesforo AUT700938678 1 I— C", HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER L ❑Y ❑N 2 G) 9N708 WATER RD VEHU 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N n NAME(LAST,FIRST,M) Bahena.Anamarie mo day yr 1 0 0 8 2 0 0 1 Honda Civic 2021 00-NONE 11,: 12 '_s RE o CRASH O ® U2 2 C I', 13-UNDER CARRIAGE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR n a` 2200 BARTER CT F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y El DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 1, 4 COM VEH 0 ® U1 F, FIRST CONTACT 7 kg.. 5 •If Yes,See Sidebar C ELGIN IL 60123 0 CX57494 IL 2025 REAR 0 f/j, m TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)943-7612 B500-0000-1887 IL D 19XFC1 F76ME009973 Progressive ❑y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Bahena, Fortino 979919287 Bnc ' 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER yo0NR 2200 BAXTER CT. ELGIN . IL.60123 (847)695-1320 u1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)I(TELEPHONE) (EMS) (HOSPITAL) n I I - U2 996 1— m / - #OCCS ' D / /• U1 1 m I I 1 0 EV MOST EVNT Loc DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 10/19 /2024 08 05 ❑pM in a Work Zone? ISI N DIRP co 1 r 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 0 20 20 ! / 0 PM El Construction * N 3 0 ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q CO 11 4 ARREST NAME Valle,Jasmine 11-709-A W1504000416 / / ❑PM SLMT o u CICITATIONS ISSUED ElPENDING •SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N BAM 50 T 2 0 ARREST NAME r / ppl Ut ❑Unknown work zone type • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 0 AM Workers present? El Y 50 1504 Real. Hilario 401 272-Bajak , p PM ElN 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 ; _r } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i I d i -` ` r r r (example.shuttle or charter bus)-or 0 X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 t.----.....---% i -i } - i transporting employees in the course of their employment(example.employee M transporter-usually a van type vehicle or passenger car).or w i_____A____: : i , : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose).or 0 L____--____; i -: 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) 71 CARRIER NAME Z ' ADDRESS 0 • N .• CITY/STATE/ZIP 2 r , MOTOR CARR ID ❑ Interstate El Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , ^ USDOT NO. ILCC NO. • , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No M 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 0 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 En 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. 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE