HomeMy WebLinkAbout2025-00002790 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 111111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a693618
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-S1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 31,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00002790 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 01 13 2025 ®AM ❑YES ®NO U1 -<
W ROUTE 20 Elgin mo /day/yr 10:40 ❑PM FLOW CONDITION m
®5 FT/® NOS W South State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR SLOW 6 co
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DOSTOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EouES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
0 3 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 04 M
M 2 SY n is-OTHER
5 ❑Y ®SNE M DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH ❑ El 1 0
~ ELGIN N I L 60123 B 1 0 FIRST CONTACT 12 7_: __5 *irYes.See Sidebar U1
Z 62858T-B IL 2026 REAR
TELEPHONE
IL D 7 2FTRX17W2XCB01000 Allstate ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Other 99 9 Same 912415486 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Provena St.Joseph ❑Y ❑ N 2 0
E{ DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES 0 row 0 rav 0 Dv
/1 9$4 Hino 258 2024 00-NONE 'o,1 t2 c,�2 DUE O CRASH 0 ® U2 13 C o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •0istracton value 9 g
POINT OF S i 4 COM VEH ® ❑ U1 IN
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 O7 ,�_QOS •If Yes,See Sidebar C
Z Joliet IL 60435 0 1 0 AANV4956 IL 2026aR 0 Si)
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IL D 0 Artisan and Truckers ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 6 x
99 9 Hooking U Up Inc. 979218088 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 1 01 /13 /2025 10 40 ®❑PM in a Work Zone? ❑N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 ❑ 28 03 01/13 /2025 10 40 ❑PM ®Construction *
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ®AM 0 Maintenance U2
-a, ARREST NAME PANTOJA.ANTONIO.Z. 11-601 1543000053 01/13/2025 10 48 ❑pM SLMT
o U 1 ® 11 1 - • 0
Utility
MI CITATIONS ISSUED 0 PENDING AM
SECTION CITATION NO. ROAD CLEARANCE TIME
t 2 El ARREST NAME Cordova. Eloy 6-303-A 1543000052 01/13 /2025 11 00 MPM 0 Unknown work zone type U1 55
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 55
1543-Sturgeon. Kyle 701 02 /25/2025 01 30 ❑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 -<
i- i•---_r__--; I INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or C
I- L.___A.._.� 3. Isdesgnedtocarry15or fewer passengers and operated bya 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
L L.___a.._..l .1 I ® �® _ } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
QA for direct compensation(example:large van used for specific purpose):or
< <____a.....I.
' Routine i "_i-_ - t } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
\ I 1 placarding(example:placards will be displayed on the vehicle). D
JCARRIER NAME Hooking U Up Inc.
ADDRESS 9920 PACIFIC AVE 1 0
cn
r r -:- 1 7 ! r
Not To Scale CITY/STATE/ZIP Franklin Park 1ILJ60131 g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
- USDOT NO. ILCC NO. 237822
xi
Source of above z
. 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 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown 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 ®No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE