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HomeMy WebLinkAbout2024-00067287 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III (III (IIIIII II 11111111111111111011111111110 I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003556438 u, 1 U21 1 1 1 U1 2 U2 1 Ut 1 U2 1 Ut 1 U2 1 1 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 El NOT ON SVEHICLE/PROPERTY El OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067287 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 N RANDALL RD ® ❑ Elgin RELATED ❑Y co" 10 21 2024 03:44 DAM ❑YES ®No u1 ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ®Y ❑N DOORING ❑Y - #OF MOTOR ®SLOW 1 U) ElFT/MI N E S W 'WITH VEHICLES INVID ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y IM " PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑ERNERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NW ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 1 2 n FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mo day yr Honda Civic 2013 00-NONE D,IETOCRASH , Edwin. F. / J ++_ +s D ❑ 21E 13-UNDERCARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 53 U2 00 m 515 AUTUMN CT 202 M ❑Y ESYlM❑LINK VEH. O AT CRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 ,Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii 4 COM VEH 0 El 1 0 a ~ 19XFB2F55DE010894 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 0350930SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU ° ❑Y ®" 2 0®DRIVER ❑ PARKED ❑ORNERLESS ❑ PED ❑PEDALL ❑EDUCE ❑Nav ❑Ncv ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m 7 / J FOR DAMAGED AREA(S) FRONT TOWED Y N 5 NAME(LAST,FIRST,M) Castro,Antonio 0 mo day 1 9 6 1 yr Nissan Altima 2014 00-NONE O' �' + DUE TO CRASH ❑ ® 2Xi 13-UNDER CARRIAGE 9 i ©I I_2 FIRE ❑ IN U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPOR n SYSTEM IN O ENGAGED 15-OTHER 9 16-TOP 3 9 0 X a` 11 N260 HAWTHORNE ST M ❑Y ® N ElUNK VEH. AT CRASH 99-UNKNOWN Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PO P RI8T NT COONTACT F 11 7_1' 8 I_5 C•IOMeeVSee Sidebar ® U1 to H ELGIN IL 60123 0 E113451 IL 2025 O CCn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)346-7944 C236-0006-1206 IL D 1 N4AL3AP1 EC181744 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 2981379SFP13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDER Same U1 = (UNIT( I SEAT) i DOBi (SEX) ;SAFT) (AIR) iINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAMEI((ADDRESSi(iTELEPHONE1 {EIdSi (HOSPITAL) 1 6 05 /31 /1986 M 2 4 0� 1 0 Guillermo J. Pacheco Ballesteros/515 AUTUMN CT 202,ELGIN,IL,60123 996 1— (630)644-6169 , U2 m 1 3 08 /22/2001 M 2 4 0 1 0 Diego F_ Pinto Gutierrez/515 AUTUMN CT 202.ELGIN,IL,60123 #OCCS D (224)402-5632 _ X / / U1 3 m / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N i ® 1 1 5 10/21 /2024 03 44 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 1 a 2 0 2 99 1 / PM ❑Construction * c' 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance uz Q 21 11 5 ARREST NAME / / ❑PM ❑Utility SLMT 0 U 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 10 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 ❑AM Workers present? ❑Y 10 1506-Nunez, Maria 502 334-Fries , , ❑PM ®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. 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. Z : l : l : 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer Z ' r • ; i ; i- r r , , i r r INDICATE NORTH combination) or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L I ', ! 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 . • - MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r ,-•---, i '- DO ILCC NO. m U N XI , •• • Source of above Z • . 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 En Brown White - u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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