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HomeMy WebLinkAbout2025-00002133 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 11011111100 IM DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0036896 9 u, 1 U21 3 4 3 U1 4 U2 1 u, 1 1_12 1 u1 1 U2 1 5 11 u1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00002133 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 01 10 2025 ®AM ❑YES El NO U1 3191 ROUTE 20 HWY Elgin PRIVATE mo /day/yr 05:54 ❑PM FLOW CONDITION m 01 O(�!MI N E S © Nesler Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 Co Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 �i DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRO TOWED U1 Q Cruz-Ce a.Juan. P. 0 9 1 yr 13-UNDER CARRIAGE ©,I '.-2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 4 COM VEH ❑ j$J 1 O F- Hampshire IL 60140 B 1 1 FIRST CONTACT 12 7 ; _-5 *II Yes.See Sidebar U1 Z P EV12442 IL 2025 E TELEPHONE IL D JTDBT923971060018 State Farm ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same 0780985SFP13 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ❑ N 3 2 X x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑MAV 0 i v ❑DV 1 9$4 Ford F450 2019 00-NONE ,._j t2..-_, DUETO CRASH ❑ ® 14 ,'a o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 3 X ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iI 6 1',_4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 Y__{_O _5 •If Yes,See Sidebar — Hebron IL 60034 0 1 0 155447F IL 2025 REAR 0 C n IL D 1 FD9X4GT1 KEC04222 Amerisure ❑y ISI N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Berger Excavating Co CA21017620801 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP ui = KNIT) (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 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 11 ,01 )025 05 54 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 28 11 ) ) ❑PM ❑Construction * Z3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 o1 ® 11 1 ARREST NAME Cruz-Ceja.Juan. P. 11-601 298001180W r r El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 45 r 2ARREST NAME AM 7 1 r ❑❑pM ❑Unknown work zone type U1 Eln OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 45 298-Lopez, Mirko 801 - r { ❑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 -< i- ;---.r----; No. combination):or —I INDICATE NORTH 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 il `- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w C L L.___a__...I. dN— 4. Is used ordesi nated to trans rtbetween9and15passengers,includingthedriver, . . . for direct compensation(example:large van used for speific purose):or O N nRd' t i. i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires r� A Not To Scala i rI placarding(example:placards will be isplayed on the vehicle). ePTGasTsaron CARRIER NAME a19tTROU[e72eTFNry. Z ADDRESS 0 w C) CITY/STATE/ZIP g , w MOTOR CARR.ID El Interstate El Intrastate , 1 Pdm7or7Impact. ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 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 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 Blue Red 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE