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HomeMy WebLinkAbout2025-00001560 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�003f50812 u, 1 U21 3 4 1 U1 3 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U1 1 U2 S .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00001560 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ®Y ❑N 01 08 2025 ®AM ❑YES ®NO U1 -< S RANDALL RD Elgin 00:13 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1 FT!MI N E S W SOUTH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) r'tr�TOWED U1 0 mo Munoz Garcia.Juan. M. Acura MDX 2008 00-NONE ©1 >2 �/OUETOCRASH ® ❑ NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10.I • 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 0 I'll M 2 SYTM IN ENGAGEis-OTHER 5 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 7 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 5 *II Yes.See Sidebar U1 COM VEH 0 j$J 1 0 F. FIRST CONTACT 12 7,. __ Z SOUTH ELGIN IL 60177 0 1 0 EL58021 IL 2025 I , TELEPHONE IL D 0 2HNYD28608H543409 State Farm ❑Y ICI N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same E95-6710-B31-13C 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 Ixv 0 CIRCLE NUMBER(S) U1 DV yr Jeep(after 198��riot 2013 00-NONE O1 Qj_O DUE TO CRASH 0 D 2 x 0 13-UNDER CARRIAGE FIRE ❑ ® U2 C c M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distracter)Value 3 POINT OF s i COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:_ C FIRST CONTACT 11 7 _5 C.!ryes.See Sidebar ELGIN IL 60124 B 1 0 DK17142 IL 2024 I 0 Si) IL D 0 1 C4NJRFB9DD137453 American Alliance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same I LAA-0954456-00 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 m / / ##OCCS y Pj / / UI 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 01 ,08 ,2025 00 13 ®❑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 C) v 2 0 25 28 01,08 /2025 00 13 ❑PM ❑Construction * R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2 3 ®AM ❑Maintenance U2 —a, ARREST NAME Munoz Garcia.Juan. M. 11-306 1518000356 01,08/2025 00 57 ❑pM SLMT 1 ® 11 1 ISI CITATIONS ISSUED 0 PENDING Utility aNSECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑ o t 2 ❑ ARREST NAME Mata Mendez.Vincente. D. 3-413-F 1518000357 01/08 /2025 00 54 [fl PM 0 Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1518-Versetto. Elisa 801 391-Jacobucci 02 , 18,2025 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 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 -< ` ` -' -' JIMA r INDICATE NORTH combination):or -IBY ARROW2 Is used or designed to transport more than 15 passengers including the driverCi ® - (example:shuttle or charter bus):or r r r X L L A 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 i. i. __}----+ - - I. } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. I for direct compensation(example:large van used for specific purpose):or O L L____a____. _ t i 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires uos placarding(example:placards will be displayed on the vehicle). XI ( ._I - — — — CARRIER NAME Z ADDRESS 0 ® C Not To Scale I C) CITY/STATE/ZIPg - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i— --- "1 - USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 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 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 Gray Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Owners Residence . 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