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HomeMy WebLinkAbout2025-00002158 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Dt 2 Sheets 01111101111 01101100 II 01 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403689678 u, 1 U21 1 1 3 U1 2 U2 7 U, 1 U2 1 U, 1 U2 1 1 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 El$501-$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 2025I 2025-00002158 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 WING ST Elgin ® ❑ RELATED ❑Y ®N 01 10 2025 E�IAM ❑YES El NO U1 -< PRIVATE mo /day/yr 09:00 ❑PM FLOW CONDITION M ®75 ®!MI N E S © North State St COUNTY PROPERTY ❑Y ® N DOORING ❑V #OF MOTOR ❑SLOW 1 fA Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 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 n FOR DAMAGEDAREA(S) FROM TOWED U1 Q NAME(LAST,FIRST,M) Gasca. Mercedes mo / 13-UNDER CARRIAGE 19 i 'a:2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 M F 2 4 El ®SNE❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UUNKNOWN 916-TOP S `Distraction Value 9 ALGN = 1• 6 COM VEH 0 Ea 1_s *Irves.seesidabar Ut CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 :i;1 4 0 ZFIRST CONTACT 12 Y ELGIN IL 60123 0 1 0 EF IL 2019 _ TELEPHONE IL D 2HGFC2F60KH572047 STATE FARM ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 Same 0383381-SFP-13 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y El 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv /1 9 9 2 Nissan Altima 2021 00-NONE +i_"i 12..-_, DUE TO CRASH ❑ C 2 o 13-UNDERCARRIAGE 10-1 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 0 POINT OF 8 II 4 COM VEH D ® Ut W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - Mk_ FIRST CONTACT 6 Y :j_ -5 •If Yes.See Sidebar — Rolling Meadows IL 60008 C 1 DQ58939 IL 2025 i 9 N Z IL D 1 N4BL4CVXMN304398 PROGRESSIVE ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 Same 973674079 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) 2 6 08 / 2 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 01 /10 /2025 09 00 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 v 2 ❑ 28 03 01,10 /2025 09 22 ❑PM ❑Construction >F R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ®AM ❑Maintenance U2 o El 11 1 ARREST NAME Gasca. Mercedes 11-601-Ax 367000120 01,10/2026 09 26 ❑PM SLMT igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility o N 0 AM 25 T 2 ❑ ARREST NAME Gasca. Mercedes 6-303-A 367000119 , / PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 24 367-Stein.Andrew 501 01 ,27,2025 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 NADDITIONAL UNITS FORMS. r ----r••--, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z p ` 1 .1 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -< } } ' ' - 1 ``L 71.�i i INDICATE NORTH combination):or p0 St to S BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 111 1 (example:shuttle or charter bus):or 1 l 1 r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O < }.___A_._.� = 1 1 - y } transporting employees In the course of their employment(example:employee X ` `11 l r } transppoorterg-usall a van type vehicle or passenger car): r L }-----}----; = ` t - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, ' , for direct compensation(example:large van used for specific purpose):or < <____a____,I. Wing9St =,;_„ Q I _ } } } t 5. Ilan vehicle(exanyused toa transport hazardous materialehcle),(HAZMAT)that requires m _., placarding(example:placards will be isplayed on the vehicle). ;p --- 1 I I i -- —1 I I CARRIER NAME Z _ __ ADDRESS D n I I I CITY/STATE/ZIP g I, I - MOTOR CARR.ID 0 Interstate 0 Intrastate ii — ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ' "Y --4. _ I I USDOT NO. ILCC NO. vxm I = r J E m XI Source of above z . 0 Yes J No ❑ Unknown 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 VIM 1 m co 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 Blue Silver 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/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE