HomeMy WebLinkAbout2025-00000496 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III HH II11II UHI U 111111111111111110111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a€81533
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY N OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00000496 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 01 03 2025NAM ElYES El NO U1 -<
S RANDALL RD Elgin mo /day/yr 07:02 ❑PM FLOW CONDITION III
10 ®!MI O E S W Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
01 1 /
yr 11-_ 12 -
13-UNDER CARRIAGE 10l 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iII a t.i_4 COM VEH 0 )g! 1 n
~ SOUTH ELGIN I L 60177 B 1 0 FIRST CONTACT 6 O::L:Q_O •IfYes.See Sidebar U1 0
Z BD80860 IL 2025 . E
TELEPHONE
IL D 0 1 G N KRG KDOGJ330725 State Farm ❑Y Igi N U2 r 1 R
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Elgin Fire Saturnino.Gasper 2129543SFP13 4 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 XI
��, E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 RED 0 PEDAL 0 EWES 0 i My 0 KDV ❑DV
/2 0 0 3 Honda Civic 2017 00-NONE �"' Q!'-O DUE TO CRASH rg ❑ 2 x
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13-UNDER CARRIAGE 10( I 2 FIRE ❑ El C
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F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y 10 N DUNK VEH. AT CRASH 99-UNKNOWN `Oistract Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1:,-4 COM VEH ElN U1 CO
FIRST CONTACT 12 7� -.5 •If Yes.See Sidebar
m ELGINREAR
M IL 60123 B 1 0 EW20118 IL 2025
IL D 0 19XFC2F79HE081326 The General ❑Y N N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Ladron De Guevara.Gonzalo 1 BIL6677040 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
1 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 ,12 /25 07 02 ❑PM in a Work Zone? ®N DIRP D
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1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
0 2 0 1 2 07 20 11 r 12 /25 07 08
❑PM• ❑Construction >E
R 3 ❑ igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
-a, ARREST NAME Salinas Cardenas. Karina 11-801 369002186 1/ /12 /25 07 20 ❑PM SLMT
1 ® ElUtilit 11 1 N CITATIONS ISSUED 0 PENDING
o NSECTION CITATION NO. ROAD CLEARANCE TIME AM y 45
r 2 ❑ ARREST NAME Salinas Cardenas. Karina 11-601 369002187 1/ //2 /25 07 55 fl PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
369-Varga.John 702 275-Engelke 1/ , 81 /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 truck trailer -<
c ` ''- ' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
■me.,axra _ (example:shuttle or charter bus):or
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I I I 10115.14.41.111
"'�"" N I. - . transporting mployeened to sl5 or fewer In hecourseeo their eers mplod yment(example:example:employeerier X
I,e d I I transporter-usually a van type vehicle or passenger car):or w
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I I nrofTOaysrJ . 4. Is used ordesi nated to trans rt between 9 and 15passengers,includingthedriver, C
Y I I t F } for direct compensation(example:large van used for speific purose):or
—1-1-1-- I t t t 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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I I I j I i placarding(example:placards will be displayed on the vehicle). XI
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1 I `N ` CARRIER NAME Z
�"_tI. ADDRESS D
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - '-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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
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LOCAL USE ONLY TRAILER VIN 2 m
0
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
Red Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 4 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE