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HomeMy WebLinkAbout2024-00068328 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003604210 u, 1 U21 1 1 1 U1 1 U2 2 U, 1 1_12 1 U, 1 U2 1 1 10 U1 3 U2 3 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 202412024-00068328 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn 455 BLUFF CITY BLVD Elgin 01:29 ® ❑ RELATED ❑Y ®N 10 26 2024 ❑AM ❑YES ®NO U1 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 20 9 0 Ford Fusion 201 6 00-NONE FOR DAMAGEDAREA(S) FRONT TOWED U1 NAME(LAST,FIRST,M) Garcia Flores. Heriberto mo / / yr 13-UNDER CARRIAGE ©i O - DUE TO CRASH ® ❑ FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0U2 2 f11 M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a �i 4 COM VEH 0 j$J 1 0 ELGIN IL 60120 0 1 0 FIRST CONTACT 11 7_; -__5 *IrYes.SeeSidebar U1 Z EU73757 IL 2025 REAR TELEPHONE IL D 0 American Alliance ❑Y Igl N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same ILAA-0980601-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused 0 Y ® N 2 XI g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m,lv 0 RGV 0 Dv /1 9 6 5 Dodge Caravan(inc Grand)2018 oo-NONE 11_"j Q�-_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( I FIRE 0 ® U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COMVEH ❑ ® U1 CO FIRST CONTACT 12 7 _, -5 •If Yes.See Sidebar = ELGIN IL 60120 0 1 0 BR15160 IL 2025 I 0 IL D 2C4RDGCG5JR21560 State Farm ®Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X Same K171634-E14-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) 1 3 07 / D / / 3 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 10/26 /2024 01 29 ®PM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T o" 2 0 2 99 / / 0 PM• ❑Construction Z3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 6 —a, ARREST NAME Garcia Flores. Heriberto 11-601 457-562 / / El PM SLMT o N 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility AM 30 f 2 El ARREST NAME Hernandez Garibo.Ana. L. 3-707 457-561 / / 0 pM ElUnknown work zone type U1 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 457-Fearol. Megan 401 272-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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; 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 INDICATE NORTH combination):or .Z-1 N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r I _ } (example:shuttle or charter bus):or Not To scale J 0 L L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0 } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w e m. I I 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N unva j m.von.ddsrai. for direct compensation(example:large van used for specific purpose):or O __ ®(va Nal an GICi� _ i. < L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ® l placarding(example:placards will be displayed on the vehicle). D ror CARRIER NAME I I I I I I I I I I_ - ADDRESS O 66899411900.1. ®' '"' ''6 CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i— --- --1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE