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HomeMy WebLinkAbout2024-00068284 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets liii Ill DIII III )III 1111 lull II 111111111111111 111011 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2316 u, 1 U21 1 1 1 U1 5 U2 5 Ut 1 U2 1 Ut 1 U2 1 1 12 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 EI NOT ON SVEHICLE/PROPERTY 0 OVER$1.500 ❑AMENDEDCENE(DESK REPORT) ❑ B Injury and JorTow Due To Crash YR 2024I2024-00068284 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 '1'1 KIMBALL ST ❑Elgin RELATED ❑Y coN 10 26 2024 08_26 ®AM ❑YES ®NO U1 ,•< PRIVATE mo /day I yr ❑PM FLOW CONDITION m Eel e()I MI N E s® North ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg oRNER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑ECUES ❑NIA/ ❑acy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FRONT TOWED Ut O 0 5 / 0 1 J 1 9 8 0 General Motors an 1997 00-NONE D,IETOCRASH NAME(LAST,FIRST,M) ,Gilberto mD day yr 11- 12 I -1 ID ❑ 3 13-UNDER CARRIAGE 10 2 FIRE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 m 614 DOUGLAS AVE M SYSTEM IN ENGAGED t5-OTHER 9 16-TOF� I PLATE NO. STATE YEAR POINT OF 16 ii_ COM VEH 0 0 1 0 1GDFK16RIVJ717861 STATE FARM ❑Y ®N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 1 99 9 GUITERREZ, NANCY, R. 0124458SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L RESPONDER 9 612 DOUGLAS AVE 1. ELGIN , IL.60120 (872)218-1346 VEHU GI GI 5 ®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 FOR DAMAGED AREA(S) FRONT TOWED Y N NAME(LAST,FIRST,M) BELMAN HERNANDEZ,OLGA, L. 0 6 2 JUa 1 9 y 5 Subaru Impreza 2012 00-NONE 1t 12 1 Due ro CRASH ❑ 0 2 XI v t3-UNDER CARRIAGE 10 j ! 2 FIRE ❑ 0 U2 C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 SPDR SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 O E 775 JEFFERSON AVE 1 F ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 01 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT T COONTACT 8 �'� 6 6 COM VEH ❑ 0 Ut If Yes,See Sidebar ELGIN IL 60120 0 Q618117 IL 2025 m•. C.n M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (224)688-9111 B455-6527-5777 IL D 0 JF1 GPAD62CH216183 STATE FARM ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I 1 99 9 Same 2447478-SFP-13 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER 996 < 0 YOND rij N 9 Same U1 = (UNIT( I SEAT) ;DOB) (SEX) (SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)I(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 06 /23/2313 M 2 3 0 1 0 MATEO L. DE LALUZ/775 JEFFERSON AVE 1.ELGIN.IL.60120 - 996 r (224)688-9111 , U2 m 2 4 05 /0 9/2013 M 2 3 0 1 0 GUSTAVO RODRIGUEZ/775 JEFFERSON AVE 1.ELGIN,IL-60120 #OCCS D (224)688-9111 _ X / / U1 1 m • / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N ® 11 1 10/26 ,2024 08 26 ❑pM in a Work Zone? ®N DIRP D 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 3 T 2 0 20 28 ! / 0 PM ❑Construction * N 3 0 izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 AM ❑Maintenance U2 Q CO 11 1 ARREST NAME Fuentes.Gilberto 6-303-A 374001282 / / ❑PM SLMT o U CITATIONS ISSUED PENDING • ROAD CLEARANCE TIME 0 Utility n ❑ ❑ SECTION CITATION NO. II AM 25 o N 2 0 ARREST NAME 1 / ptil El Unknown work zone type U1 2 2 3 0 • OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? 0 Y 25 374-Rizzu-o. Michael 1o1 272-Bajak 12 ( 21 /024 01 30 ®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. _ 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 1". Z 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer -< r 'I 1 i combination) or INDICATE NORTH 711 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' .- :- I 1 j I I -! ` r r r (example'.shuttle or charter bus)-or n I I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 i-- -:-- -- 4 I I I -i 'r 'r - transporting employees in the course of their employment(example.employee 71 transporter-usually a van type vehicle or passenger car).or 03 i-____A____: : : i r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N —— — for direct compensation(example:large van used for specific purpose).or L_____:_____1 2 ~` i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires O — 71 placarding(example placards will be displayed on the vehicle) m — Z1 ra ll I I �.m8a.. CARRIER NAME I I I Z 0I I I ADDRESS I I I to CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. Not in Comm./Other . USDOT NO. ILCC NO. , Source of above Z . ❑ Yes ❑ No ❑ Unknown E 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 — X IDOT PERMIT NO WIDELOAD? ❑Yes ❑No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m TRAILER WIDTH(S) 0-96'1 97-102'1 >102 m m TRAILER 1 ❑ ❑ ❑ Z -74 TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft. Z Black Blue - 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