Loading...
HomeMy WebLinkAbout2024-00072841 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II OUI 0011001HHI DII 11011110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a628912 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 1.11 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202412024-00072841 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m ® ❑ RELATED ®Y 0 N 11 17 2024 ®AM ❑YES ®NO U1 —< SUMMIT ST Elgin06:58 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W HILL LL AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 _ TOWED U1 NAME(LAST,FIRST,M) Modesto Lozano. Ma Antonia mo yr Jeep(after 1968jand Cherokee 2006 00-NONE Q Off, 0DUE TO CRASH ® 0 13-UNDER CARRIAGE 10 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn F 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRAS IN H 9 15-OTHER 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�6 �i COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_: __5 *II Yes.See Sidebar U1 Z DN15680 IL 2025 REAR TELEPHONE IL D 1J4GR48K96C157545 Kemper ❑Y ®N U2 M B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co PEREZ. EDUARDO 12au001045730 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y 0 N 2 eu m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m,ly 0 NOV 0 Dv CIRCLE NUMBER(S) U1 !1 9 6 6 Toyota Camry 2016 00-NONE O 2 -_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 6 I ©Ic 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16•TOP 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 11:, 4 COM VEH 0 ® U1 CO FIRST CONTACT 11 7�RFJ ,__5 •IfYes.See Sidebar = ELGIN D IL 60120 0 1 0 Z641803 IL 2022 IL D 4T1 BF1 FK8GU545769 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same k403928d2413 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 11 ,17 l2024 06 58 ®❑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 5 C) T o� 2 0 2 15 ) ! ❑PM ❑Construction X R 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Modesto Lozano. Ma Antonia 11-601-Ax 483000283 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 35 r 2 ❑ ARRESTNAME AM T 1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 483-Lynch, Miriam 300 272-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 truck trailer -< c ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X L A e 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X rter- enger or co L ...l. i 42lsuosedordesgnatedtotranslly a van type portbetweeicle or n9a d15rpassen rs,includingthedriver, C _ } } for direct compensation(examp large van used for specific purpose):or 0 L L____a____. Adi" T - t l. I any I 5. Is any vehicle used to transport hazardous material(HAZMAT)thatrequires placarding(example:placards will be displayed on the vehicle). m 1 / CARRIER NAME Z .... ® - __ ADDRESS 0 V) _Not To Stele. ' i. i. i. i. 4. 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------- - USDOT NO. ILCC NO. rn XI Source of above z . 0 Yes 0 No ❑ Unknown A 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'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Other/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 ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE