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HomeMy WebLinkAbout2024-00074068 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I01101100 II ifiI VIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036 3.1,a u, 1 U21 2 4 1 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 5 10 u1 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00074068 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED ®Y 0 N 11 23 2024 ®AM ❑YES ®NO U1 -< BIG TIMBER RD Elgin05:52 _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION Ill FT!MI N E S W HILLCREST LLCREST RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I COAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 3 ! yr 13-UNDER CARRIAGE ) 2 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0 m M 2 8 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _ CI N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 1,.4 COM VEH 0 )g! 1 C) ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; __5 *If Yes.See Sidebar U1 Z3463882B IL 2024 TELEPHONE IL D 5TFHY5F14DX295531 State Farm ❑Y ®N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Ortiz,Jose,J. 1165178SFP13 1 1- 5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 ou m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 !1 9 9 9 Toyota Sienna 2004 00-NONE 'o,1 t2 (,�2 FIRE DUE O CRASH 0 D U2 2 C .. 13-UNDER CARRIAGE El c M 2 8 SYSTEM IN ENGAGED 15-OTHER g©TppE3�* 0 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istrac on Value POINT OF 8 i II 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 3 O7 ,� _:5 •IfYes,See Sidebar ELGIN IL 60120 A 1 0 EL18350 IL 2025 REAR 0 C IL D 5TDZA22C14S014905 Bristol West ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Tellez.Armando G01401399301 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Sherman RESPOND❑N 3 u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 11 ,23 /2024 05 52 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) iii 2 2 23 11,23 ,2024 05 53 ❑PM ❑Construction E R 3 ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ®AM ❑Maintenance U2 -a, ARREST NAME Ortiz,Jessy.A. 11-901-A 298001159 11,23,2024 05 56 ❑PM SLMT o U1 ® 11 4 I&CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ElUtilit y r 2 El ARREST NAME Ortiz,Jessy.A. 11-1204-B 298001160 11/23 ,2024 07 00 f PM 0 Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 298-Lopez, Mirko 8813 272-Bajak 12 ,09,2024 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. r ----r•---, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z r combination):. Hasor more than pounds(example:truck or truck trailer 1. Has a weight rating10 000 INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or y� , r 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0 < } -- i esgpa g pe by 9 I - } } } 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 transport passengers,including y} } } g po passen rs,includi the driver, 1W, for direct compensation(example:large van used for specific purpose):or o L L.__-a..... - l. ii. t 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires �;,,',C.: placarding(example:placards will be displayed on the vehicle). XI m I. t 0 CARRIER NAME Z 4 ADDRESS 'n Il D 1 0 Not To Scale CITY/STATE/ZIP g I o I MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"-------1 - USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m a 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 Gray Silver 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 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