Loading...
HomeMy WebLinkAbout2025-00003022 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 HH 1111 II 111111111111011111011 IOHIOD DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4036D8165 u, 1 U21 1 1 1 U1 4 U2 1 U, 1 U2 1 U, 1 U2 1 1 6 U, 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00003022 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m 170 RT20 EB Elgin08:53 ® ❑ RELATED ❑Y ®N 01 14 2025 ®AM ❑YES ®NO U1 -< _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 16 Cn ❑ FT,MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 T TOWED U1 0 NAME(LAST,FIRST,M) mo /1 9 9 5 Ford Ranger 2001 00-NONE ©, DUE TOCRASH ® ❑ OO 13-UNDER CARRIAGE I O FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rr1 M 2 5 ❑Y ®N SYSTEM ❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1, 4 COM VEH 0 Ea 1 0 H 1- E LG I N I L 60123 0 1 3848390B IL FIRST CONTACT 11 T_; __s Yes.See sidebar Ut Z REAR E TELEPHONE IL 0 1 FTZR15E71 PA30905 Direct Auto ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same PAIL001225071 4 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 eu g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑INv 0 NOV ❑DV yr Peterbilt Moto Co. 2025 00-NONE 631 �j.0 DUE TO CRASH p (g► 21 o 13-UNDER CARRIAGE 1. FIRE ❑ ® U2 C M 2 4 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value POINT OF s i 4 COM VEH ® ❑ U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 1:._ C FIRST CONTACT 11 7 -L-5 •If Yes.See Sidebar H Woodstock IL 60098 0 1 85499X WI I 0 IL 7 1 NPCL40X5RD678900 Federated Mutual Ins ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Petrochoice Transport Inc 9866787 BAC 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) W 1 0 / F m / / #OCCS D 71 / / U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 24 2 01 ,14 l2025 08 53 ®❑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 2 ® 11 1 11 28 ! , ❑PM ❑Construction >F Z 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME Torrez Hernandez.Juan.J. 6-101 465-008 , ! El PM SLMT o N 1 ® 24 2 igiCITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility AM 50 Ti 2 El1 1 1 ARREST NAME Torrez Hernandez.Juan.J. 11-601-A 465-009 , , 0 pM El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? ❑Y 50 465-Doracio.Ariana 401 275-Engelke 02 , 18,2025 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 truck trailer -< i- }--_.r-_--; combination):or —I INDICATE NORTH p1 N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or rmuerm II X A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O - } I- I- I- transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans transport passengers,including C} } } g po passen rs,includi the driver, ' for direct compensation(example:large van used for specific purpose):or o I I < <____a____� orA pO' - t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m yx' placarding(example:placards will be displayed on the vehicle). XI♦ 2# �ne2- CARRIER NAME Petrochoice Transport Inc. Z pir ADDRESS 3301 JAM ES DAY AVE o CITY/STATE/ZIP Superior 1 WI 154880 o I Not To Scale MOTOR CARR.ID 0 Interstate El Intrastat0 e 5 I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other � --------1 - USDOT NO. 226518 ILCC NO. m 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? 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 ®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 Black White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: _Arties . 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