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HomeMy WebLinkAbout2024-00068075-original , l III ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Il ii Ill OIl III 1In ll 111111111111111111111111 III II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL 'MANY X0036022 1 u, 1 U21 1 1 1 U1 1 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away Elgin Police Department ONE PERSON'S ®$501-$1.500 ®ON SCENE 1 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 0 AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00068075 VEHT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m N STATE ST El ❑ Elgin RELATED ❑Y coN 10 25 2024 12:06 ❑AM ❑YES ®NO U1 .( PRIVATE mo /day I yr ®PM FLOW CONDITION m 0543/MI O E S W WING St 'COUNTY PROPERTY ElY ®N DOORING ❑y #OF MOTOR ElSLOW 3 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —1 El AT INTERSECTION WITH (NAME OF ) PEDALCYCUST®N [] FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EOUES 0 NW 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FRONT TOWED Ut Ford Transit ConnectO 2020 00-NONE 0 DUE TO CRASH 0 NAME(LAST,FIRST,M) .J. mo 1 2 / day J yr 11-1 1s 13-UNDERCARRIAGE 10l , 2 FIRE 0 21 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 10 U2 4 m 1700 FOXFI E LD DR M THER ❑Y ®N SYSTEM❑UNK VEH. O AT CRASH O 99-UNKNOWN 9 16-TOP 3 ,Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 (I 5 I( COMVEH El ® 2 0jL FIRST CONTACT 1 7 :I___,.._5 •Irves,See Sidebar U1 0 Z 1 FDBR1C62LKA54577 LIBERTY MUTUAL FIRE INS. ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a ELITE MEDICAL TRANSP AS2641445106013 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER o RESPONDER E 11551 184TH PL.Orland Park, IL.60467 (708)478-8880 VEHU 73 ®DRIVER ❑ PARKED 0 DRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑Ncv 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 4 m m / J FOR DAMAGED AREA(S) FRC IT TOWED Y N , NAME(LAST,FIRST,M) MATA CASTI LLD,ALMA, D. lmo ay 1 9 yf 5 Honda Pilot 2004 00-NONE 11: 12 Z RE o CRASH p❑ ® U2 2 C v 13-UNDER CARRIAGE c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 IN SPOR n a 483 GREGORY AVE 1A F SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 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 II�^/�I� 4 COM VEH ❑ ® U1 to FIRST CONTACT 6 7_:d_' L5 •If Yes,See Sidebar Z GLENDALE HEIGHTS IL 60139 0 DW83204 IL 2025 MAR 0 (n D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)848-0192 M322-0047-5914 IL D 0 2HKYF18664H570335 KEMPER ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I MATA CASTILLO.ALMA- D. 12AU001574602 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER POONR 2313 GLENDALE TER 7. HANOVER PARK, IL.60133 U1 = (UNIT) (SEAT) ;DOB( (SEX) (SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)i(TELEPHONE( (EMS( (HOSPITAL) 1 3 10 /1 9/1998 M 2 4 0 1 0 NICHOLAS E. SEVERIN/1145 39TH ST,DOWNERS GROVE,IL.60515 996 r (708)478-0880 , U2 m 2 3 09 /28/1991 M 2 4 0 1 0 JOHAN GUZMANROMERO/1825SRIDGEWAY AVE-CHICAGO.IL.60623 #OCCS D (773)209-1926 _ / / Ut 2 m / / 2 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 10,25 /2024 12 06 ®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 1 C) T 2 ❑ 28 99 ! / 0 PM ❑Construction * 1 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ElAM El Maintenance U2 1 Q CO 11 1 ARREST NAME / / ❑PM ❑Utility SLMT O U ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 'd N IIAM 35 2 0 ARREST NAME , I ptil ❑Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME El Y 35 244-Blomberg. Michael 501 272-Bajak , , ❑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 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS 4 } 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 truckrtrailer -< r i ; i r r , , 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 '. ' t ` ` ` ' ' '. ' ' 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------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 al ' 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 mV placarding(example placards will be displayed on the vehicle) 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----, i r - 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? O ❑ 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 xi 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 White White - 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_ 1 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE