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HomeMy WebLinkAbout2024-00068458 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III I IIII lull 111111111111111111101011 IIIII DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036O2325 u, 1 U21 1 1 1 U116 U2 1 U, 1 U2 1 Ut 1 U2 1 4 9 Ut 1 u221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1,500 ®ON SCENE 2 El NOT ON SVEHICLE/PROPERTY ill OVER$1.500 0 AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00068458 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION ' DATE OF CRASH TIME SECONDARY CRASH 15 't'1 GEORGE ST ❑Elgin RELATED ❑Y coN 10 27 2024 00_20 ®AM ❑YES ®NO U1 •< PRIVATE mo /day/yr ❑PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y M N DOORING ❑Y #OF MOTOR ❑SLOW 1 U) El FT/MI N E S W WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF ) Kane HIT&RUN ®Y 0 N PEDALCYCUST®N ® FREE FLOW # LNS 0 DA DRIVER 0 PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EOUES 0 SIN 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 7 / 0 9 /2 0 0 5 FOR DAMAGEDAREA(S) FROM TOWED U1 mo day yr 12 D 13-UNDERCARRIAGE Z FIRE ❑ ® 10 O < SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 1SI U2 m 406 CROMWELL CIR M ❑Y ®SYSNEM DUNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 9 76-TOP 3 Distraction Value ALGN = CITY PLATE NO. STATE YEAR POINT OF 8 it li-4 COM VEH 0 IZI 1 C) m FIRST CONTACT 1 7 :tom -5 •If Yes,See Sidebar U1 0 Z 1C4RJFCT4LC198629 National General ❑Y ®N U2 m Le. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a 99 9 Same 2024672691 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER '' RESPONDER Same VEHU X L ❑Y ®N 2 G� 0 DRIVER ® PARKED 0 CRNERLESS 0 PED ❑PEDAL 0 EOUES 0 NUN ❑NCV 0 ON DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N Ut m m / / FOR DAMAGED AREA(S) FRONT TOWED n NAME(LAST,FIRST,M) mo day yr Nissan 370Z 2012 00-NONE 1 , 1$ '_1 DUE TO CRASH ❑ ® 1 XI c 13-UNDERCARRIAGE of I: 2 FIRE El Ill U2 C c STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 IN SPDR X ❑Y ® N DUNK VEH. AT CRASH 99-UNKNOWN © 4 •Distraction Value U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF COM VEH ❑ ® C FIRST CONTACT 7 Q. _,.t 6 I'.5 •It Yes,See Sidebar 20860WS IL 2025 riaii 0 C M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JN1AZ4EH6CM561920 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 I 99 9 Thanadabouth. Michael. M. 2236801SFP13 BAC 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 996 < 0 Y RESPONDER 1754 NEWBRIDGE CIR. ELGIN . IL.60123 (331)218-8470 Ut = (UNIT) (SEAT) iDOBi I SEX' (SAFT) (AIR) IINJI IEJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)r{ADDRESS)r(TELEPHONEI (EMS (HOSPITAL) 1 3 09 /29/2004 M 2 4 0 1 0 Brian Morales 1159 PERRY ST-ELGIN.IL.60123 996 r (224)465-6055 U2 m / / #OCCS D /• / ut2 m I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 18 1 10/27 /2024 00 20 �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 a5 C) T 2 ® 18 1 28 99 ! / 0 PM ❑Construction * t N 3 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME Ei AM ❑Maintenance U2 5 Q ARREST NAME Espinoza. Edwin. R. 11-708 1512420 / / ❑PM SLMT 1 ® 11 1 , 0 Utility p U ®CITATIONS ISSUED ❑PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME N AM 25 t 2 ❑ ARREST NAME Espinoza. Edwin. R. 11-708 1512421 r / 8 ptil El Unknown work zone type Ut 2 2 3 " 0 OFFICER ID SIGNATURE BEAT J DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 25 1512-Juarez-Huichapan.Juan 400 - 11 r 12/2024 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 ; 3 0 A CMV is defined as any motor vehicle used to transport passengers or property and. Z 1 Has a weight rat rig more than 10,000 pounds(example truck or truckrtrailer r ; - — 0 _; ; combination).or INDICATE NORTH XI Ei a+g' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J. J. ', i s -` ` r r r (example'.shuttle or charter bus)-or 0 7 i.. ----� 4 i + it } itransportingdesigned employees inthe course of theiremployment(example�emaployeerier 0 3. I s f nsporter-usually a van type vehicle or passenger car).or CO ____A____: : , r i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, C 4627C�orq�7St for direct compensation(example:large van used for specific purpose).or O L____"____; i i 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires �K placarding(example placards will be displayed on the vehicle) -13 rn • • w 2. CARRIER NAME Z ' t ADDRESS 0 • N . O CITY/STATE/ZIP r , - MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 0 Not in Comm./Govt. El Not in Comm./Other ^ USDOT NO. ILCC NO. m 9entlsc 11 , Source of above Z . 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 2 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 Red Black u 1 TOWED - - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO: DUE TO © VEHICLE CONFIG CARGO BODY TYPE LOAD TYPE