HomeMy WebLinkAbout2025-00001619 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II l 1001111 tI ll
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a690191
u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 u1 1 u2 1 *P 0119*
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 ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00001619 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 mW HIGHLAND AVE El In08:05
® ❑ RELATED ' V 0 N 01 08 2025 ®AM ❑YES El NO U1
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION MI
FT l MI N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR El SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 n
FOR DAMAGEDAREA(S) FROr tf TOWED U1 Q
Hernandez.Alejandro 0 6 /
yr . Q
13-UNDER CARRIAGE �0 i : 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 8 rr1
M 1 2 4 ❑Y ®SNEM UNK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s :i1 6 �i,4 COM VEH El El 1 0
F. FIRST CONTACT 1 7_;—--___5 *I(Yes.See Sidebar U1
Z Chicago IL 60629 0 1 0 137562F IL 2025 fAii
TELEPHONE
IL B 1 FC3E3KS7GDC44407 Travelers Property Casual ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Domestic Linen Suppl TC2JCAP466K9064TIL23 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 nuv 0 NCv 0 DV
!1 9 y yf 8 Ford F150 2005 00-NONE O, Qj-_, DUETO CRASH 0 ❑ 2 73
o 13-UNDER CARRIAGE 10 I Ic. 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 15-OTHER 9 16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i 6 i.', COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 , _5 •If Yes.See Sidebar C
n ELGIN IL 60123 0 1 3740410B IL 2025 I 0 N
Z
IL D 1 FTPW14505KD80199 Progressive ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 987423486 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 12 /
:A
/ / UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 01 ,08 l2025 08 05 ®❑PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
T
0 2 ❑ 25 2 ! ! ❑PM ❑Construction X
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Hernandez.Alejandro 11-305-A 340000121 / / El PM SLMT
o Nu ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
30
t 2 0 ARRESTNAME AM
T 1 ! ❑❑PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
340-Phillips. Kathryn 600 275-Engelke 02 , 11 ,2025 09 00 ❑PM Workers present? ®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
r .
I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
i- }--_.{-----; ( combination):or -1
INDICATE NORTH 71
III Abt SScabI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I I [ N i. e. r (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I �a - y } } } transportingemployees in the course of their employment
IL..
f—� (example:employee �
1 1 1 ® transporter-usually a van type vehicle or passenger car):or W
L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a----. /j - � ; 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
J 1 I f I""^� �j placardig(example:placards will be isplayed on the vehicle). XI
J -- —�!
CARRIER NAME Domestic Linen Supply Company z
®\ Ibi. i. ADDRESS 30555 NORTHWESTERN HWY 300 0
�I '' �® Z
i- 'r -i- i I i Ii
CITY/STATE/ZIP Farmington Hills I MI 148334o I 1 MOTOR CARR.ID 0 Interstate El Intrastate
1 I . 1 I I ❑ Not in Comm./Govt. 0 Not in Comm./Other0
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes ® 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 ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II ❑No 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 ®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
White Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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