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HomeMy WebLinkAbout2024-00067218 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill OIl III I IIII lull 111111111111111 11101 lUll 1111 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003602353 u, 1 U21 2 4 1 U199 1.12 1 U1 9 U2 1 U1 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT LE A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 0 NOT ON SVEHICLE/PROPERTY Ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00067218 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1 SLADE AVE ® In ❑ RELATED ®Y ❑N 10 21 2024 10:25 ®AM ❑YES ®NO U1 ,< g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W DUNCAN ) Kane HIT&RUN ❑Y CZN PEDALCYCUST®N 0 FREE FLOW # LNS 0 tg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PEE 0 PEDAL ❑EOUES 0 NIN 0 Ncv 0 on DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 4 / 0 5 /1 9 8 9 FOR DAMAGED AREA(S) FRCNT TOWED Ut 0 . Ivan Chevrolet Malibu 2008 00-NONE 0' ..'�..D DUETOCRASH ❑ ® - E NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE tU z FIRE 0 IA < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ISI U2 m 1856 SCARBORO DR M SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 = / ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 8 4 'Distraction Value ALGN r CITY PLATE NO. STATE YEAR POINT OF . • COM VEH 0 El 1 00 iL FIRST CONTACT 12 7_.; 6--_I:_.5 •Yves,See Sidebar U1 Z 1 G 1 ZH57B48F239492 State Farm ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR a Same 1551666 SFP 13 1 m o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER .. RESPONDER Same VEHU L ❑Y ❑N 2 0®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 Nay ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 m m FOR DAMAGED AREA(S) FROM TOWED Y N n NAME(LAST,FIRST,M) Powers. Ian. M_ 0 8 / I /da 1 9 9 0 Dodge Ram 1500(pickup) 2019 00-NONE yr 13-UNDER CARRIAGE tt l 12I. 2 RE TO CRASH O ® U2 2Xi v _ C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 0), DISTRACTED 0 IN SPDR 0 SYSTEM IN ❑Y ENGAGED 15-OTHER O9 16-TOP 3 a 0` 845 ST JOHN ST M ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ©III 6 li 4 COM VEH ❑ ® U1 to I— FIRST CONTACT 1 O 7___1 5 •It Yes,See Sidebar ELGIN IL 60120 0 3347751B IL 2025 REAR 0 fn M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (630)209-9369 P620-4139-0229 IL D 1 C6SRFFT7KN577625 Geico ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same 4360925848 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < 0RE Y ONR Same U1 = (UNIT ;SEAT) IDOBi (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME!,(ADDRESS),ITELEPHONEI (EMSt (HOSPITAL) 0 2 3 1 2 /1 1 /1991 F 2 4 0 1 Ashley M. Powers/845 ST JOHN ST,ELGIN,IL,60120 U2 996 m / / #occs y 1 / / U1 m D. / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 1 1 4 10,21 /2024 10 25 ❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM Ut 5 ,. 2 0 2 14 ! / 0 PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance uz Q • ARREST NAME Olvera-Ramirez. Ivan 11-901-A 414-972 / / ❑PM SLMT ® 11 4 0 Utility p U ❑CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME o N 8 AM 30 2 0 ARREST NAME / / ppl ❑Unknown work zone type Ut 2 2 3 El Am ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 414-Lara. Raul 102 272-Bajak 11 , 19/2024 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. r 0IF 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. Z r-"--r----, , 1 r r r r r , , , 1 . r 1 Has a weight rating more than 10,000 pounds(example.truck or truckrtrailer -< r i ; i r r , , i r r INDICATE NORTH combination) or — r"0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ' t ` ` ' ' 1 ` ` r r r (example'.shuttle or charter bus)-or X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 -----'-----• + I I. ' J 1 1 1 i } - i- transporting employees in the course of their employment(example.employee M . I transporter-usually a van type vehicle or passenger car).or w r i- 4 Is used or designated to transport between 9 and 15 passengers,including the driver, 9 Po P 9 N for direct compensation(example:large van used for specific purpose).or O ' 1 i i 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example placards will be displayed on the vehicle) 71 M CARRIER NAME Z ' .. ADDRESS 0 N • CITY/STATE/ZIP 2 MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other Q r-----.-----, r r r r - -, r • - UDO N ILCC NO. m 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 Form Number 0 M 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 >102 m T TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Silver 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