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HomeMy WebLinkAbout2024-00067536 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II II 010 Ifi 1In ll 11111111111111111011111100 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X00355E457 u, 1 U21 1 1 1 UI 7 U2 1 U, 1 U2 1 U1 1 U2 1 5 11 Ut 1 u211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON VEHICLE/PROPERTY inOVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067536 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 W CHICAGO ST El ❑ Elgin RELATED ❑Y coN 10 22 2024 06:39 ❑AM ❑YES ®No u1 ,•< PRIVATE mo /day/yr ®PM FLOW CONDITION m r4'000/MI N E S® RIVERSIDE ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRNER ❑ PARKED ❑CRNERLESS ❑ PED O PEDAL ❑EOUES ❑NIN ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n 0 6 / 0 6 /1 9 7 6 FOR DAMAGED AREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) . Maribel mo day yr Toyota RAV4 2018 00-NONE 11 O1 , DUE TO CRASH ❑ 21 13-UNDERCARRIAGE 101• I 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® U2 02 m 213 HENRY ST F ❑Y INNSYST DUNK VEH. 0 AT CRASH O 99-UNKNOWN THER 9 76-TOP 3 .Distraction Value 9 ALGN 2 CITY PLATE NO. STATE YEAR POINT OF 8 {I� 4 COM VEH 0 ® 1 0 a JTMRFREV8JD253656 STATE FARM ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 ARREGUIN RAMIREZ. ISRAEL 0137094SFP13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r RESPONDER L ❑Y ®N 213 HENRY ST, ELGIN , I L.60120 VEHU 73 2 05 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑ECUED 0 WV ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m / / FOR DAMAGED AREA(S) FRONT TOWED Y N s Pa an-Omar 0 7 2 5 1 9 8 0 Mitsubishi Outlander 2021 00-NONE tt. i'_t DUE TO CRASH ❑ DA 2 —I , NAME(LAST,FIRST,M) g ©, C c mo day yr t3-UNDERCARRIAGE 10, fj 2 FIRE 0 ® U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR n E. 167 S CLIFTON AVE M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 9 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 i ' 4 COM VEH ❑ ® U1 C FIRST CONTACT 6 7_- -_1 ;_5 ••(rYes,See Sidebar ELGIN IL 60123 0 DU69520 IL 2025 l 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)915-9508 P250-6408-0211 IL D JA4APUAUXM0001092 PROGRESSIVE ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 986066330 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDERY Same U1 = (UNIT( I SEAT) (DOS) (SEX, i)SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 06 /1 7/2009 M 2 4 0 1 0 Omar X. Pagan/167 S CLIFTON AVE.ELGIN.IL.60123 996 r (224)769-1763 U2 m 3 6 02 /26/2017 M 2 4 0 1 0 Omar Ortiz Santillan/1122 BIRCH DR 3.ELGIN-IL-60120 #OCCS D (815)557-0336 _ XI 3 5 09 /1 5/2015 F 2 4 0 1 0 Meredith Ortiz Santillan/1122 BIRCH DR 3,ELGIN.IL.60120 U1 1 m (815)557-0336 D 3 4 10 /29/2019 M 11 4 0 1 0 Santiago Ortiz Santillan/1122 BIRCH DR 3-ELGIN-IL-60120 0 (815)557-0336 U2 2 2 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y N 1 ® 1 1 1 10/22 /2024 07 01 ®PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 C) T 2 ❑ 03 28 ! / 0 PM ❑Construction * N T 3 ❑ izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 Q ARREST NAME Garcia Lopez. Maribel 11-710-A 1506-289 / / ❑PM SLMT ® 11 1 0 Utility p U ❑CITATIONS ISSUED El 'SECTION CITATION NO. ROAD CLEARANCE TIME rn B AM 30 I 2 ID1 1 1 ARREST NAME , / ptil ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30 1506-Nunez. Maria 101 334-Fries 11 , 12/2024 09 00 ❑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. 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS RrvERSIDE4RD -� A CMV is defined as any motor vehicle used to transport passengers or property and. 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r '. i ; 1 — — — — — — — ; : combination) or —I INDICATE NORTH XI \ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. ', i I ! ` r r r (example'.shuttle or charter bus)-or 0 i_-----;-----• + i I aN -t } } t transporting! 15 or fewer the course of their employment(example�emapbYeerier 3 -usually a van vehicle or �____A____: : , g L [— Not 7h Scab f i r i 4trIs ansporter ordesgnatedto rpansportbetween 9 and ger15rpassengers,including the driver, C g . 5 P.O.I, for direct compensation(example:large van used for specific purpose).or O -____"-____; i , z I po.l. t i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m mI I ` placarding(example placards will be displayed on the vehicle) 71 UNIT 1 CARRIER NAME Z I ADDRESS 0 To . C) g F CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate El Intrastate IIIIIIIIuI111I�IIIIIIII11IIuuII11II ❑ Not n Comm w Not n Comm/Other/G t ❑ Q r , USDOT NO. ILCC NO. m , Source of above Z . Form Number 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 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 2 ft. y Maroon Black - 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