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HomeMy WebLinkAbout2024-00066884 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III III OIH III II 0 10 II II NH IIIIIIIIIIIIIIIIIIIIIIIIIIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XQO3593624 u, 1 U21 1 1 1 Ut 5 U2 1 Ut 1 U2 1 Ut 1 U2 1 4 10 Ut 4 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury J Drive Away Elgin Police Department ONE PERSON'S 0$501-$1,500 ®ON SCENE 1 El NOT ON VEHICLE/PROPERTY ElOVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00066884 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 RAYMOND ST ® D Elgin RELATED ®Y ❑N 10 19 2024 07:45 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E S W DWIGHT ST 'COUNTY PROPERTY El ®N DOORING ❑y #OF MOTOR 0 SLOW 1 U) ❑ 'WITH VEHICLES INVLD El STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N ® FREE FLOW # LNS 0 110 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nav ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 4 / 0 6 /1 9 9 4 FOR DAMAGEDAREA(S) FRO 1T TOWED U1 9 mo day yr 12 13-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) to O DISTRACTED 0 ® U2 2 m 1277 GETZELMAN DR F THER ❑Y ®SYsNEM IN❑UNK VEH. n AT CRASH ENGAGED 0 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF 8 6 • 4 COM VEH ❑ ® 2 O a 1 FMCU9J91 FUB97986 American Alliance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Same ILAA072401502 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER •'' RESPONDER Same VEHU 73 L ❑Y ®N 2 0®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDALL ❑EQUES 0 NW ❑soy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m s 0 6 / 2 5 /1 9 9 8 FOR DAMAGED AREA(S) F TOWEDiE g NAME(LAST,FIRST,M) Riatiga Almeida. Eduardo.A. Ford Fusion 2011 00-NONE t3-UNDER CARRIAGE ,t IRONT + CRASH 0 ® 2 xi 12 '- TL c mo day yr I : c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® 2 FIRE El IN U2 DISTRACTED 0 ® SPUR n E 362 RAYMOND ST M Y SYSTEM IN O ENGAGED 0 15-OTHER 016-TOP 3 X ❑ El ElUNK VEH. AT CRASH 99-UNKNOWN ® 4 'Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COONTACT 1 O 7_'I a •'_5 •GIOMesVSee SidebaEH r ® U1 to H ELGIN IL 60120 0 EW87021 IL 2025 REAR 0 fn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (469)837-9734 R324-2019-8180 IL D 0 3FAHPOHA3BR167201 Safeway Insurance Co ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 41245211LPP001 BAG• 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < 0 IZI N Same U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 996 1 3 10 /30/1997 M 2 4 0 1 0 Reyes G. Rojas/1277 GETZELMAN DR.ELGIN,IL,60123 U2 m m 2 6 1 2 /25 2023 F 13 4 0 1 0 Roma R. Martinez/362 RAYMOND ST.ELGIN-IL-60120 #OCCS D 2 4 04 /02/2000 F 2 4 0 1 0 Yaddy Martinez/362 RAYMOND ST-ELGIN-IL-60120 Ut 2 m (2241762-2402 D 2 3 10 /29/1999 M 2 4 0 1 0 Sebastian F. Riatiga Almeida/362 RAYMOND ST,ELGIN-IL-60120 0 (224)290-2413 U2 4 0 EV MOST EVNT Loc DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur 0 Y Z N ® 11 1 10,19 /2024 07 45 ®pm in a Work Zone? ®N DIRP D 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 20 06 ! I 0 PM ❑Construction * cc 3 ❑ ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 El AM Maintenance uz ❑ Q CO 11 1 ARREST NAME Rojas Vargas. Maria, D. 11-708 51526000259 / / ❑PM SLMT o U ❑CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility NAM 30 2 0 ARREST NAME 10/19 /2024 08 15 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1526-Walsh.Jacob 401 246-Kite 11 26/2024 01 30 ®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 0IF 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 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i• ; i r r , , i r r INDICATE NORTH combination) or 'I ."0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C '. ' t ` ` ' ' 1 ` ` 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 mV placarding(example placards will be displayed on the vehicle) . ` CARRIER NAME Z ' ADDRESS 0 N • CITY/STATE/ZIP . - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q m r-----.-----, r r r r r----, r '- DO ILCC NO. m U N XI , Source of above Z . ❑ 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 7a 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Gray 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