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HomeMy WebLinkAbout2024-00068162 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets liii Ill OIl III I IIII lull 111111111111111 1110111111 Ill II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2301 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 U2 1 Ut 1 U2 1 1 12 Ut 2 U2 1 *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 2 0 NOT ON S VEHICLE/PROPERTY 0 OVER$1.500 El AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2O24-00068162 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'F'I LILLIAN ST ®gin ID ❑Y coN 10 25 2024 05:00 ❑AM ❑YES ®No u1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m 02° ®/MI N E S® South Clifton ) PEDALCYCUST®N ® FREE FLOW # LNS 0 tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 (7 0 5 / 0 2 /1 9 9 2 FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) mo day yr Hyundai Elantra 2017 Do-NONE ®® ©I , DUE TO CRASH ❑ 21 13-UNDER CARRIAGE 2 FIRE ❑ El 2 < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 53 U2 m 345 J O H N DR F SY❑Y ®N SE DUNK VEH. n AT CRASH M IN ENGAGED0 99-UNKNOWN 9 16-TOP 3 .Distraction Value ALGN 2 r CITY PLATE NO. STATE YEAR POINT OF 8 iI _ 11-4 COM VEH 0 El 1 0 ra 5NPD84LF3HH130595 Kemper Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y 99 9 Same 12Av001500244 1 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r o '' RESPONDER Same VEHU L ❑Y ®N 2 17 ®DRIVER ❑ PARKED 0 cRNERLESS ❑ PED 0 PEDAL ❑EQUES 0 WV ❑NCv ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N U1 m m 5 / / FOR DAMAGED AREA(S) FRONT TOWED TLOi W CRASH D NAME(LAST,FIRST,M) Villalva-Camilla 0 mo day2 8 2 0 O 4 yr Toyota Echo 2003 Do-NONE 11_ ,s 0 ❑ ® 2 Xi v 13-UNDER CARRIAGE 10 1 z FIRE ❑ 21 U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 IN SPUR 0 a 386 N CRYSTAL ST F SYSTEM IN O ENGAGED 9 15-OTHER 9 16-TOP 3O O X ❑Y ® N ID UNK VEH. AT CRASH 99-UNKNOWN8 Distraction Value H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POF FIRST CINT OONTACT 1 7_ 6 • OS CUOYeaVSee Sidebar ® UT C C Elgin IL 60123 0 DY99320 IL 2024 REAR0 (/) M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (331)222-1945 V441-1000-4814 IL D 0 'JTDBT123735045893 Kemper ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL 'VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 99 9 Villalva-Joaquin 12Au001102835 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER 386 N CRYSTAL ST. Elgin. IL.60123 (847)483-4670 U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS 8 WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE I (EMS) (HOSPITAL) C) I I - U2 996 1— m - #OCCS y 73 / / U1 1 m I I 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 9 10/25 /2024 05 00 0 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 7 C) T 2 0 04 99 / I 0 PM El Construction * N 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 AM ❑Maintenance U2 Q ARREST NAME Nava. Mariana 11-703-B 1528-000160 / / ❑PM SLMT ® 11 1 ❑Utility p UCITATIONS ISSUEDPENDING ROAD CLEARANCE TIME o N 0 0 SECTION CITATION NO. AM 30 2 0 ARREST NAME 10/25 /2024 05 10 ®PM 0 Unknown work zone type U1 T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? D Y 30 1528-Rivera. Kevin 701 - 11 /26/2024 01 30 0 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 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 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 ElIntrastate ❑ 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 . 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 m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ o u 1 COLOR u 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Black Gray - 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