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HomeMy WebLinkAbout2024-00067283 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111 DIII III I III lull 111111111111111110111111111 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E43 U112 U2 1 1 1 U116 U2 Ut 1 U2 Ut 1 U2 1 6 Ut 1 U2 *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 ❑$501-$1.500 ®ON SCENE 8 0 NOT ON VEHICLE/PROPERTY inOVER$1.500 ❑AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067283 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT FLEETWOOD DR ❑Elgin RELATED ❑Y coN 10 21 2024 03:41 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day/yr ®PM FLOW CONDITION m ®1 Q�i/MI NOS W South ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 ECUES 0 Nmi 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 / 0 7 /1 9 9 7 FOR DAMAGED AREA(S) FRONT TOWED U1 mo day yr z _ ©-UNDER CARRIAGE i _ z FIRE ❑ ® < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 111 U2 m SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 22 AU STI N AVE M / ❑Y ❑N ®UNK VEH. 9 AT CRASH 9 99-UNKNOWN 8 4 'Distraction Value ALGN . r CITY PLATE NO. STATE YEAR POINT OF 16 li O COM VEH 0 ® 1 0 ~ 1GCPSBEK2R1192222 Unknown ❑Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR Same Unknown 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L El ®N 2 GI 0 DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED fi 1 DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo day yr 00-NONE 10 12 C c 13-UNDER CARRIAGE 101 I 2 FIRE ❑ ❑ U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 0 SPOR 17 ❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value UI 0 - POINT OFCa N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT T_II 91_S CIO VEH 0 C H p • C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER 996 < 0 YOEl N Ut = (UNITE (SEAT) ;DOB) (SEX) TSAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) C) W 1 1 /20/1995 F Natasha M Locklin/ 4130 LARAMIE LN -Rockford.IL.61108/ U2 r (224)508-5742 m / / #OCCS D / / ut1 m I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur 0 Y U2 Z 1 N 1 ❑ 1 3 Buena Vista Tree on SE corner 10,21 ,2024 03 41 ®PM in a Work Zone? Ill N DIRP CO PROPERTY OWNERS ADDRESS:STREET.CITY.STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: U1 3 a T 2 El 41 AM 41 3 1285 FLEETWOOD DR ELGIN IL 60123 17 99 10,21 /2024 03 41 ®PM ❑Construction * c' T 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME z J ❑AM ❑Maintenance U2 ARREST NAME Villagomez.Jesus 3-707 494000338 10/21 /2024 03 41 ®PM SLMT o U 1 ❑ Igl CITATIONS ISSUED 0 PENDING TIME 0 Utility o NSECTION CITATION NO. ROAD CLEARANCE AM 3O ¢ T 2 ❑ ARREST NAME Villagomez.Jesus 6-303-A 494000337 / B pM ❑Unknown work zone type U1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ❑ 494-Kirsh. Katherine 701 334-Fries 11 , 18/2024 09 00 M 0 p Workers present? ®Y N 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 -----.-----; ; i ; 0 } 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 1 - 1 INDICATE NORTH combination) or XI Net 7b Sow I 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 n S M101 "e00L 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i------i-----% 4 i -i } } i transporting employees in the course of their employment(example employee transporter-usually a van type vehicle or passenger car).or CO i-____A____: : , _ : i , 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N 3 for direct compensation(example:large van used for specific purpose).or O L____ ____1 i .,,y,� i 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires y� 11 "of.5 placarding(example placards will be displayed on the vehicle) m 71 CARRIER NAME Z ' ADDRESS 0 • N o CITY/STATE/ZIP s Malan Ofte. - MOTOR CARR ID ❑ Interstate ❑ Intrastate - ❑ Not in Comm./Govt. Not in Comm./Other t ) t USDOT NO. ILCC NO. m , 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 C z Form Number 0 _ m — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. TOWED BY/TO: DUE TO VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE