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HomeMy WebLinkAbout2024-00075185 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 011111100 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003643611 u, 2 U2 1 1 1 U116 U2 U, 1 U2 u, 1 U2 1 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202412024-00075185 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn INDIAN DR Elgin 07:17 ® ❑ RELATED ❑Y ®N 11 28 2024 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W ELMA AVE COUNTY PROPERTY ❑Y 2�1 N DOORING Ely #OF MOTOR 0 SLOW 1 cn ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 1 0 ! yr 13-UNDER CARRIAGE ©i O- FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) O O DISTRACTED 0 ]$I U2 2 �T1 F 2 8 ❑Y ®SYSNEM IN❑LINK VEH. O AT CRASH ENGAGED O 99-UUTHER NKNOWN 9aTIDPO `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_.,—iL B ii,4 COM VEH 0 j$J 1 0 F. FIRST CONTACT 1 7_ _;__5 *Irves.See Sidebar U1 Z Carpentersville IL 60110 A 1 0 BX91649 IL 2024 REAR TELEPHONE IL D 0 1C3CDZAB7DN726165 N/A El ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Leon. Maria. D. N/A 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER RESPONDER 1 CXI )) a DRIVER I} PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Niuy 0 v 0 Dv yr 0 13-UNDER CARRIAGE 10( 2 FIRE ID El U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16 ❑ -TOP 3 9 0 X a Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value • POINT OF 8 ) .4Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH 0 ® co F,,, FIRST CONTACT 7 O7 ,�=QI1._5 •If Yes.See Sidebar V258787 IL 2025 REAR 0 fn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2CNDL13F656137856 Unique ❑Y 123 N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Solis.Yarisved I LP329412 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 18 1 11 ,28 ,2024 07 17 ®AM in a Work Zone? ®N DIRP co I NI PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 ❑ 08 28 11,28 ,2024 07 18 ®PM ❑Construction >F R 1 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ❑AM ❑Maintenance U2 -a, ARREST NAME Lara. Lesly 11-601-Ax 752466 11,28,2024 07 23 ®PM SLMT o U 1 ® 11 1 ISI CITATIONS ISSUED 0 PENDING Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME AM' t 2 El ARREST NAME Lara, Lesly 3-707 752467 hi28 l2024 08 00 0 PM El Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1532-Hernandez. Daniel 201 12 , 17,2024 10 30 ElPM ®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 -< f r____Y____1 111701ELMA4AYE 1,2141.11M41tlJE.11309lLIM4AY! 11344ELM114AVE r INDICATE NORTH combination):or -I 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 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 } } } transporting employees in the course of their employment(example:employee X - transporter-usually a van type vehicle or passenger car):or w i. `-----:----i t I . 1 I LL11_I_1111 L I I_ll1_LI_L1L_1 I 1 1 L11J_-L1_1.tll_ti11 - I. F I• I• 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C for direct compensation(example:large van used for specific purpose):or t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI 0 B.MA?AVE. - -- '{ . CARRIER NAME Z ADDRESS D $ (n C) CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate _rra m sir. O I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -""Y""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 v TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 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 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE