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HomeMy WebLinkAbout2024-00067878 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II II I III OIH III 1III1011 lIOfl IHO I DI I D 11111111 III DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003599123 u, 1 U21 1 1 1 U146 U2 1 U, 1 U2 1 U1 1 U2 1 1 9 U1 1 U221 *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 SVEHICLE/PROPERTY ®OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2024I2024-00067878 VENT * ADDRESS NO. •HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 ADAMS ST ® ❑ Elgin RELATED ❑Y coN 10 24 2024 01:08 ❑AM ❑YES ®No u1 ,•< PRIVATE mo /day I yr ®PM FLOW CONDITION m 080 ®I MI N E s® ) PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑ORNERLESS ❑ PED ❑PEDAL ❑EOUES 0 ssv 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGED AREA(S) FitO4T TOWED Ut O NAME(LAST,FIRST,M) 1 0 / 1mo day yr 8 J 2 0 0 3 Toyota Camry 2008 00-NONE „ .i 0 1D /�DUEFIRE TO CRASH ®D ll❑ - E 13-UNDERCARRIAGE 1 z < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® U2 m 406 S STATE ST F SYTM❑Y INS ME ❑UNK VEH. O AT CRASH D O 99-U 15-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = THER I"' CITY PLATE NO. STATE YEAR POINT OF 6 i 6 4 COM VEH 0 ® 5 C) m jL FIRST CONTACT 1 7_ ? .5 •Yves,See Sidebar U1 p Z 4T4BE46K68R043922 Geico 0 v ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m JUAREZ MORALES.GERMAIN 6177883664 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r L RESPONDER 406 S STATE ST. ELG I N . I L.60123 (224)402-0894 VEHU 0 0 DRIVER ® PARKED 0 CRNERLESS 0 PED ❑PEON. ❑EOUES 0 NMV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Ut 2 m m / / FOR DAMAGED AREA(S) Fi20 IT TOWED Y N s General MotorSi�PEp 2016 00-NONE 1 i DUE TO CRASH ❑ ® 1 NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE OI 12 I. _2 FIRE El ® U2 C v STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR X ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 ui 0 POINT OF 6O ' 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR COM VEH 0 ® to 1— FIRST CONTACT 7 O7 1—6 .5 •It Yes,See Sidebar C 3516985 IL 2025 I 0 I;p M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 3GTU2NEC9GG355475 Bristol West Ins Co ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Celaya-Adan G01286235103 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 1013 ADAMS ST. ELGIN . I L.60123 (630)405-4876 U1 = (UNIT' i SEAT) (DOB! (SEX) (SAFT) (AIR) IINJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME!HADDRESS)/(TELEPHONEI (EMS! (HOSPITAL) 1 4 1 0 /02/2023 F 13 3 0 1 0 Adriel Hernandez Luna/406 S STATE ST,ELGIN-IL-60123 U2 996 r (224)428-9866 / / #OCCS D / / ul 2 m / / 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur El U2 Z N 1 ® 18 1 10,24 ,2024 01 08 ®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 3 C) T 2 0 28 15 ! / 0 PM 0 Construction * N 1 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM 0 Maintenance U2 3 CO 11 1 ARREST NAME Luna, Leslie 11-601-Ax 410000672 / / El PM SLMT o U 13 CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility ',3N B AM 30 2 0 ARREST NAME r / ptil ❑Unknown work zone type Ut 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AAA Workers present? ❑Y 30 410-DeLeon,Jessica 701 272-Bajak 11 ( 19/2024 01 30 ®PM IZI 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 ; _� } 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 I i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ` ', ', i I -t ` r r r (example'.shuttle or charter bus)-or • • 3 Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -- -- } - i transporting employees in the course of their employment(example.employee XI transporter-usually a van type vehicle or passenger car).or w i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N mro S70nnmelth for direct compensation(example:large van used for specific purpose).or O "-- , J , Not ToScale - ` ` 1 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m _f; + N placarding(example-placardswillbeisplayedonthevehicle) XI nn evsr ! \ - CARRIER NAME Z um ADDRESS unn z D • CITY/STATE/ZIP 0 r , MOTOR CARR ID ❑ Interstate El Intrastate 0 Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. • , Source of above Z . —I Were HAZMAT placards on vehicle? ❑ Yes ❑ No 1 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 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 ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 7a 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 >10:' m m TRAILER 1 ❑ ❑ ❑ Z 7 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Green Black u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑Lr DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage 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