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HomeMy WebLinkAbout2024-00067534 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill 010 III !III III ll II 11111111111111111011111 lUll I 111 I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00355E456 u, 1 U21 2 4 1 U1 2 U2 1 U, 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 ®$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 1=1 NOT ON SVEHICLE/PROPERTY ❑OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and/or Tow Due To Crash YR 2024I2024-00067534 VENT * ADDRESS NO. 'HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'FI SOUTH ST Elgin ❑ RELATED ®Y ❑N 10 22 2024 06_26 ❑AM ❑YES ®No U1 -< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W S EDISON ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N E] FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FRONT TOWED Ut O 1 1 / 2 0 J 2 0 0 7 Chevrolet Silverado 2008 00-NONE /�DUE TO CRASH NAME(LAST,FIRST,M) mo day yr 11-1 12 0 21 E 13-UNDER CARRIAGE FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 1l U2 O m 36W178 SOUTH ST M T. ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UNKNOWN THER 9 16-TOP 3 Distraction Value 9 ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 {I 6 ii-4 COM VEH 0 ® 1 0 1GCEC14X68Z138806 American Family ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Vazquez Martinez. Dulce 410425792896 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET CITY,STATE,ZIP PHONE NUMBER o RESPONDER 36W017 SOUTH ST. Elgin- IL, 60123 (224)323-1660 LIV 0 5 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 NUN ❑NCV 0 by DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m 1 / J FOR DAMAGED AREA(S) FRONT TOWED Y N , NAME(LAST,FIRST,M) DE LA PAZ. HUGO lmo ld y 1 yr 9 9 3 Toyota Corolla 2014 oo-NONE 11 12 s REoCRASH ❑❑ ® U2 2 C v 13-UNDER CARRIAGE , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C0 a` 521 S ALFRED AVE M SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 9 0 X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N PO NT F 6 II O COM VEH ❑ ® U1 07 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F RIST COONTACT 5 17__.1 e Ir —.... �.0•byes See Sidebar ELGIN IL 60123 0 Q755118 IL 2024 FEAR 0 1 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)318-6284 D412-3209-3328 IL D 0 5YFBU RH E3EP036683 Statefarm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Pinedo-Anna Marie. L. 2172924SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 521 S ALFRED AVE. ELGIN - IL.60123 (224)523-9622 U1 = (UNIT) I SEAT) (DOB) (SEX) (SAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME i/(ADDRESS)((TELEPHONE I (EMS) (HOSPITAL) 1 1 07 /1 2/1983 2 3 0 1 0 Dulce Vazquez Martinez/36W017 SOUTH ST,Elgin,IL,60123 Refused 996 ,- (224)323-1660 , U2 m / / #OCCS D / / UI 2 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 1 ® 1 1 4 10/22 /2024 06 26 ®PM in a Work Zone? ®N DIRP D 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: 0 T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM U1 7 a 2 ❑ 2 99 ! / 0 PM ❑Construction * N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ElAM ❑Maintenance U2 ARREST NAME Garcia,Julian 11-901 W1500000280 / / 0 PM SLMT 1 CO 11 4 0 Utility p uCITATIONS ISSUEDPENDING ROAD CLEARANCE TIME o N 0 0 SECTION CITATION NO. AM 35 l 2 0 ARREST NAME 10/22 /2024 06 26 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1500-Chew. Marie 601 334-Fries 10 /22/2024 06 26 ®PM Workers present? ®N U2 35 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 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I I . 0" 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 truck/trailer Z ' r • ; i ; i- r r , , i INDICATE NORTH combination).or —I • XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' L ', ', ! ( L ' ' '. ', ' f ` r r r (example'.shuttle or charter bus)-or n S ; 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 ,3 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 El Intrastate ❑ Not in Comm./Govt. ElNot in Comm./Other Q C r-----.-----, r r r r r----, ir - DO ILCC NO. m U N XI , • Source of above Z . 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? ID 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 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 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 Blue White - 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