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HomeMy WebLinkAbout2024-00067481 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III (III Ill III 111111111111111111101111011111 fill DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0035E403 u, 1 U21 1 1 1 UI 7 U2 1 U1 1 U2 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 El NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067481 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 TI N MCLEAN BLVD ® ❑ Elgin RELATED ❑Y coN 10 22 2024 02:21 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day/yr ®PM FLOW CONDITION m ®10 ®/MI N E S® EASY St 'COUNTY PROPERTY ❑Y ®N DOORING 0 Y #OF MOTOR ❑SLOW 1 U) Kane HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ❑ FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑ORNERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nmi ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) 0 2 / 2 0 /2 0 0 1 FOR DAMAGED AREA(S) FRONT TOWED U1 as. Norver, E. Toyota Prius 2013 00-NONE „ ,I. DUE TO CRASH 0 21 NAME(LAST,FIRST,M) ) mo day yr © 13-UNDERCARRIAGE 1D 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 4 m 9 LYNCH ST 1 M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 I / ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN S 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF 116 I( COM VEH ❑ El 1 C) F FIRST CONTACT 12 7 tt_ . _5 •If Yes,See Sidebar U1 0 Z JTDKN3DU1 D5651736 Unique Insurance ❑Y ®N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR rn a 99 9 Santiago. Manuela QILP6712118 2 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER r o RESPONDER 9 LYNCH ST 1. ELGIN . IL.60123 (214)243-7465 VEHU G1 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUV ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N s Hawkins,Cathleen,C. 0 8 1 2 1 9 7 0 Ford Focus 2014 00-NONE ,t �' , DUE TO CRASH ❑ ® 2 NAME(LAST,FIRST,MI mo day yr ©, Xi v 13-UNDER CARRIAGE 10 II Y FIRE ❑ ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPUR C) E 1220 MALLARD DR F SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 j /��( 4 COM VEH ❑ ❑ U1 to F, FIRST CONTACT 6 7__•-_1 ;_5 •IfYes,See Sidebar ELGIN IL 60123 0 CA70571 IL 2025 FIB 0 (n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)456-3353 H252-1037-0829 IL D 0 1FADP3K28EL429797 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 2264545SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 YRESPONDER Same U1 = (UNIT) (SEAT) (DOB( (SEX) (SAFTI (AIR) (INJ( (EJCT( (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 6 07 /25/2024 F 13 4 B 1 Emma Rojas/9 LYNCH ST 1.ELGIN,IL,60123 - Refused U2 996 1 (214)243-7465 , m 1 4 07 /29/2003 F 2 4 B 1 Manuela Bourgeon Santiago/9 LYNCH ST 1.ELGIN-IL-60123 Refused #OCCS y (214)243-7465 _ X / / U1• 3 m Ito / I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME El AM Did crash occur El U2 Z N ® 11 1 10,22 /2024 02 21 ®pM in a Work Zone? ®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 1 T 2 ❑ 28 03 ! I 0 PM El Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 Q ARREST NAME Montes Rojas, Norver, E. 11-601 51507000325 / / ❑PM SLMT CO 11 1 ❑Utilityp U ® ' CITATIONS ISSUED 0PENDING SECTION CITATION NO. ROAD CLEARANCE TIME I 2 ID 1 1 ARREST NAME Galvan. Hugo 3-707 S1507000324 10/22 /2024 03 15 ®PM 0 Unknown work zone type U1 40 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1507-Ruiz.Alondra 602 334-Fries 11 / 12/2024 01 30 0 PM Workers present? ®N U2 40 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 F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A A. ADDITIONAL UNITS FORMS 4 N -; } A CMV is defined as any motor vehicle used to transport passengers or property and. D Not To Scale 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r I I i combination) or INDICATE NORTH 7:1 I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ', , i r -t ` r r r (example.shuttle or charter bus)-or t.-----i_----� I I t } tdesigned employeeslin the courseaof theiremployment(example�emapbYeerie r 0 3 Is f transportingnsporter-usually a van type vehicle or passenger car).or w i____A____: : , i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N s.Mae I I for direct compensation(example:large van used for specific purpose).or O __-; ; . 1 / - i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M placarding(example placards will be displayed on the vehicle) 71 CARRIER NAME Z I 1 I7 i. t ADDRESS 0 I I to '• CITY/STATE/ZIP O • ^ MOTOR CARR ID ❑ Interstate ElIntrastate • 0 Not in Comm./Govt. ElNot in Comm./Other Q " "' I II • USDOT NO. ILCC NO. m m Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No PJ 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 g Did Carrier Safety Regulations(MCS)violation contribute to the crash? JD Yes No ❑ Unknown 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 IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N 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 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z White Gray - 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. 2 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE