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HomeMy WebLinkAbout2025-00001030 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 II 01 lU Dl III 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003689767- U112 U21 1 1 1 U1 4 U2 1 U1 1 U2 1 1.11 1 U2 1 4 11 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00001030 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 �1 S RANDALL RD El in05:28 ® ❑ RELATED ❑Y ®N 01 05 2025 ❑AM ❑YES ®NO U1 —< g PRIVATE mo /day/yr ®PM FLOW CONDITION m 5 !MI N E 0 S W College Green Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 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 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM TOWED U1 I� Depaz reza.Jose 0 3 / yr 13-UNDER CARRIAGE ©,I �:: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY5 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a 4 COM VEH 0 Ea 1 0 F• Elgin I L 60124 0 1 0 FIRST CONTACT 12 7 ;1 __5 *II Yes.See Sidebar U1 Z 9DQ11464 IL 2025 Ismi- TELEPHONE IL D 0 3N1AB7AP9KY220963 State Farm ❑v ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 221957-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Provena St.Joseph ❑Y El 2 0 m N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NMv 0 NOV 0 Dv CIRCLE NUMBER(S) U1 2 O O 0 Honda Fit 2007 oo-NONE 11_"j t2..-_, DUE TO CRASH 0 ❑ 2 x 0 13-UNDER CARRIAGE 10 i 2 FIRE ❑ ® U2 C c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'1 S Y0 COM VEH ❑ ® Ut W FIRST CONTACT 6 O7 �,�=Q)OS •byes.See Sidebar ELGIN z IL 60123 0 1 0 R189431 IL 2025aR M IL D 0 J H MG D386975059462 Geico Insurance ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Diebold.Jeffery.p. 4137-40-53-71 BAC E 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) U2 996 r m ##occs y 71 / U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 01 ,05 i2025 05 28 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ai 2 ❑ 17 99 / / ❑PM- ❑Construction * Z 3 ❑ lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME De paz reza.Jose 11-601-Ax W1528-000201 / ! El PM SLMT o Nu ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility 0 AM r 2 ❑ ARREST NAME 01+05 )2025 05 28 ®PM El Unknown work zone type U1 45 T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? D Y 45 1528 Rivera. Kevin 702 , ❑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 -< c ` --I -' r INDICATE NORTH combination)or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I_ pI I I I I I ( oenege�oroemor - } r (example:shuttle or charter bus):or L A U jr. I\ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } I- . transporting employees in the course of their employment(example:employee X — — transporter-usually a van type vehicle or passenger car):or w I_ I-----}- 1 /1 c - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N r for direct compensation(example:large van used for specific purpose):or I. I_ __I_ .I _ t i i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71 placarding(example:placards will be displayed on the vehicle). ,Zmt - —I _ CARRIER NAME Z e1 ADDRESS D Is t s CITY/STATE/ nZIP 0 - i. i. i. i.1 MOTOR CARR.ID 0 Interstate 0 Intrastate Not To Sock I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 -"------"1 - USDOT NO. ILCC NO. C 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Red u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 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