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HomeMy WebLinkAbout2024-00065338 , l Ill ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii Ill DIII III 1In ll 111111111111111111111111111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602248 u, 1 U21 2 4 1 U1 3 U2 1 U, 1 U2 1 Ut 1 U2 1 4 10 Ut 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® 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/or Tow Due To Crash YR 2024I2024-00065338 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 'IT WILCOX AVE El ❑ Elgin RELATED ®Y ❑N 10 12 2024 07:58 ❑AM ❑YES ®No u1 ,.< PRIVATE mo /day/yr ®PM FLOW CONDITION m FT/MI N E S W CARR ST 'COUNTY PROPERTY El ®N DOORING ❑Y #OF MOTOR El SLOW 1 N ❑ 'WITH VEHICLES INVLD 0 STOPPED U2 —1 ® AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EOUES 0 SIN 0 Rcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 9 / O 9 J 1 9 6 5 FOR DAMAGEDAREA(S) FROM TOWED U1 O -Panto a.J,J. Ford F250 2019 00-NONE 11 DUE TO CRASH 0 NAME(LAST,FIRST,M) mo day yr 12 13-UNDER CARRIAGE 10) : 2 FIRE 0 IA SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 0 m 104 W JEFFERSON POB 582 M SY❑Y ®SNE❑UNK VEH. O AT CRASH IN ENGAGED0 99-UUTHER NKNOWN 9 16-TOP 3 Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 ),1 6 1 4 COM VEH ❑ ® 1 0 ~ 1 FT7W2B69KEC13240 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m a 99 9 Vargas.Josefina 2208127-SFP-13 1 o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r L RESPONDER 259 HOXIE AVE. Elgin. IL,60123 (847)873-7017 VEHU 73 s ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) Rostkowski_Vanessa.V. lmo day 1 9 yr8 2 Mitsubishi Outlander 2016 00-NONE 12 y OUFIREETocRasH ❑❑ ® U2 2 xi c 13-UNDER CARRIAGE 0 2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED 0 IN SPCA n a` 11 S 3628 BAILEY ST F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 0 X ❑Y ® El UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p RIST NT COONTACT F 11 7_.11 6 1_5 C•IOMesVSee Sidebar❑ ® U1 to H ELGIN IL 60123 0 Z747566 IL 2025 FIEAR 0 (n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)997-7977 R232-8788-2943 IL B 0 JA4AZ3A38GZ008769 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Same 1757691-SFP-13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0 RESPONDERY Same U1 = (UNITI I SEAT) (DOBi (SEXI (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAMEI/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 0 9 /1 6/1985 M 2 3 0 1 0 Lukask Rostkowski/3628 BAILEY ST.Plano,IL,60545 - Refused 996 1— (630)788-9272 , U2 m 2 6 02 /1 3/1990 F 2 3 0 1 0 Jessica Vilagomez/15 S ELGIN-Elgin-IL-60123 Refused #occs y (847)844-7645 _ XI 2 4 04 /28/1986 M 2 3 0 1 0 Daniel S. Villagomez/15 S UNION ST,ELGIN,IL,60123 Refused U1 1 m (8471630-5287 D / / 4 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 4 10,12 /2024 07 58 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 2 C) T 2 ❑ 23 99 ! I 0 PM ❑Construction * N ' 3 ❑ ®CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 Q CO 11 4 ARREST NAME Ramirez-Pantoja.J.J. 11-904-B 1528-000152 / / ❑PM SLMT o u CITATIONS ISSUEDPENDING ROAD CLEARANCE• TIME ❑Utility o N ❑ 0 SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/12 /2024 07 58 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1528-Rivera. Kevin 601 334-Fries 11 /26/2024 01 30 0 PM Am Workers present? ®N U2 30 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 ' ._ I ', ! i ._ ' ' '. ', ' I ` 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------.-----• + + • : - -, 1 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 . O • CITY/STATE/ZIP 0 , , MOTOR CARR ID ❑ Interstate ❑ 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 . ❑ Yes 0 No ❑ Unknown A 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 Black Black - 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