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HomeMy WebLinkAbout2025-00003097 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II UHI UU 110011101111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a6D81 1 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ® B Injury and for Tow Due To Crash YR 202512025-00003097 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 280 S RANDALL RD Elgin04:11 ® ❑ RELATED ❑Y ®N 01 14 2025 12,— ❑YES ®NO U1 -< _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 15 ' ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) •FROM TOWED U1 0Duron Serna. Eze uiel 1 0 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 m M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�a 4 COM VEH ❑ Ea 1 0 ~ Rockford I L 61109 0 1 FIRST CONTACT 12 7_; _5 *lives.See Sidebar U1 Z DZ60019 IL 2025 REAR TELEPHONE IL D SHHFK7H45LU203541 American Freedom ❑Y ®N U2 Si , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12-2455539-06 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused El ® N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NOV 0 DV 2 0 0 6 Toyota Venza 2014 00-NONE 11_ 12 _, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 101 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrael on Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i l!'4 COM VEH D ® U1 CO FIRST CONTACT 8 7 _, _5 •It Yes,See Sidebar C ELGIN IL 60123 0 1 EW18312 IL 2025 REAR Si)0 IL D 0 4T3ZA3BB6EU089595 Direct Auto ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Ibarra Carrillo.Jose.A. PAIL001224166 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 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 co N 1 El 11 1 01 ,14 /2025 04 11 ®AM in a Work Zone? ®N DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n v T 2 ❑ 2 28 / / _ ❑PM ElConstruction * Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / El PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ElUtilit y 0 AM t 2 0 ARREST NAME 01 r 14 )2025 04 53 ®PM ElUnknown work zone type U1 10 n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ID Am Workers present? ❑Y 1 O 1507 Ruiz.Alondra 801 , ❑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 - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z I1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< i- }-- -'-- --' N • INDICATE NORTH combination):or -I L Not To Scale j • W 2 Is used r designed to transport more than 1 passengers including driver BY ARROW se or ig ed transpo 5 sse rs' udin the - -- - -. - - -- - } r r (example:shuttle or charter bus):or 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 CO 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 O ams+mnaumm __ i i i •D_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p -1 1 i. i. , _ , CARRIER NAME Z ADDRESS ' fib, CITY/STATE/ZIP g _ MOTOR CARR.ID 0 Interstate 0 Intrastate T I I I 0 Not in Comm./Govt. Not in Comm./Other 0 USDOT NO. ILCC NO. C 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. XI XI 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 ❑ 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 Blue Black 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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE