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HomeMy WebLinkAbout2024-00078219 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIIl DIII 011001111100 I 0000 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003661576 u, 1 U2 1 1 1 U1 1 U2 U, 1 U2 u1 2 u2 1 6 u1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202412024-00078219 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 12 13 2024 DAM ❑YES ®NO U1 -< N SHADY OAKS DR Elgin mo /day/yr 03:00 ®PM FLOW CONDITION M 010 0/MI N E p W Jefferson Ave COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW Cl) Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EDUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 7 / yr Kia Motors Co tima 2013 00-NONE • , OUE TO CRASH ® ❑ © 13-UNDER CARRIAGE 16 1 Q 2 FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 rn M 2 5 SYSTM❑Y IN NE UNK VEH. 0 ATCRASHD 99-UUNKNOWN THER9 t6•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 1,.4 COM VEH 0 0 1 0 ~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1 Z EZ14136 IL 2025 REAR TELEPHONE IL Other 0 5XXGN4A75DG187517 None ❑Y ❑N U2 M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Gonzalez Barillas,Jailin, L. None 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE.ZIP PHONE NUMBER RESPONDER 2 ou 0 DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV yr 12 _ 71 o 13-UNDER CARRIAGE 10.i t, 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 8 - :=5 COM•I sVEH See •Sidebar❑ 0 C CO F` ----- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YONDER❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 1 3 09 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ❑ 1 3 12,13 /2024 03 00 0 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 2 ® 41 3 10 28 ! / ❑PM• ❑Construction Z3 0 'xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME Tequita Ozorio,Jairo,Y. 6-101 476000317 / / El PM SLMT o u 1 ❑ �I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility t 2 El ARREST NAME Tequita Ozorio,Jairo,Y. 3-707 476000318 12/13 /2024 03 45 ®PM El Unknown work zone type U1 30 n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 476-Ramos.Clarissa 201 334-Fries 1/ , 11 ,025 09 00 ❑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 -< i- }___-r_-__; ® INDICATE NORTH combination):or -I p1 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 „r M 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w }-----}----+ -if a • } } } •4. Is used or designated to transport between 9 and 15 passen rs,including the driver. 0 for direct compensation(example:large van used for specific purpose):or O ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). - —1 CARRIER NAME XI ADDRESS 'n V) n CITY/STATE/ZIP g Not To Scale MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other �I. - ----1 - USDOT NO. ILCC NO. rn XI Source of above Z . own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes ❑ No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE