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HomeMy WebLinkAbout2024-00073332 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 11111 1110111I 0 III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003631222 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 U2 1 U, 1 U2 1 4 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202412024-00073332 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 19 2024 ❑AM ❑YES ®NO U1 -< BOWES RD Elgin mo /day/yr 05"29 ®PM FLOW CONDITION m • ®1 7 FT/® N Q S W South RAN DALL Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n NT TOWED U1 Q Valdes Zepeda. Rafael Audi A5 2003 00-NONE 1 z O._m DUE TO CRASH 0 EN NAME(LAST,FIRST.M) p mo yr 13-UNDER CARRIAGE ©'I ©: FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) © DISTRACTED 0 0U2 04 M M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL a 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60124 0 1 0 FIRST CONTACT 12 7_; __5 *II Yes.See Sidebar Ut Z CJ51565 IL 2022 REAR TELEPHONE IL A WAUAT48H03K017352 ALLSTATE ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 811810135 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 c g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr 2 o 13-UNDER CARRIAGE 10• 1 I FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16_TOPO3 * X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistraellon Value 9 U1 0 POINT OF 8 .i�.i" 4 COM VEH D ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S FIRST CONTACT 1 7 _5 •• •If Yes.See Sidebar C Lake in the Hills IL 60156 0 1 0 EV34847 IL 2025 I 0 Si) IL D 1J8GN28K38W282864 AMERICAN ALLIANCE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 SILVA.VICTOR. H. ILAA-0986446-00 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 11 /19 /2024 05 29 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n T o" 2 ❑ 2 99 + ) ❑PM• ❑Construction * 1 _ Z3 ❑ xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 a ® 11 1 ARREST NAME Valdes Zepeda. Rafael 11-902 1506-301 / / ❑PM SLMT o N • ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility t 2 ❑ 45 ARREST NAMEAM T / / ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1506-Nunez. Maria 702 334-Fries 12 / 10/2024 09 00 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. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I ADDITIONAL UNITS FORMS. .. .. , I 0A CMV is defined as any motor vehicle used to transport passengers or property and'. Z r ,r• -, N 1. Has a weight rating more than 10,000 pounds{example:truck or truck trailer -< i- }---_r----; I ( } combination):or 77 INDICATE NORTH A Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or 0 L A I 3. Is desgned to carry 15 otr fewer passengers and operated by a contract carrier O n } } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y- - - - - - •} } for direct compensation(example:large van used for cific ur mdudi the driver, Pe ( P 9 Pe purpose):or O L i t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ill placarding(example:placards will be displayed on the vehicle). ,Z) UNIT2 D I _1 P.O.I. CARRIER NAME Z _I r BOWES?RD - ADDRESS D UNIT 1 I V) CITY/STATE/ZIP n - i. i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate 5 . ; I ❑ Not in Comm./Govt. Not in Comm./Other i— --- --1 - USDOT NO. ILCC NO. m PCI Source of above z . ❑ Yes 0 No 0 Unknown g Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ YesA No 0 Unknown 0 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' T TRAILER 1 ❑ ❑ 0 z ri TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE