HomeMy WebLinkAbout2025-00003907 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
0110110 11 I I 1 1111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a69a479
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 13
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00003907 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
257 RAYMOND ST EIIn07:00
® ❑ RELATED 0 Y ®N 01 10 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED ❑Peoa- 0 eaves 0 RIAv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Castillo Gomez. Marcos,A. m0 3
13-UNDER CARRIAGE 101 �. 2 FIRE 0 IE• <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 SY4 ❑Y ®SNEM IN n DUNK VEH. 0 AT CRASH 0 99-UUTHER NKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a iI all,,4 COM VEH 0 Ea 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 7 tz::,: _-5 *II Yes.See Sidebar U1 0
Z ED83641 IL 2025 REAR
TELEPHONE
IL D 0 1 C4RJ FAG6GC478130 Alteza ❑Y Igl N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 12AU001573788 9 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr Chevrolet Trail Blazer 2003 00-NONE 1i_ 12'pm DUE TO CRASH ❑ 2 �7
o 13-UNDER CARRIAGE I FIRE ❑ ® U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10. DISTRACTE000
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * 0 ® SPDR
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN Distraction value 9 U1 0
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��',_ COM VEH D jg CO
FIRST CONTACT 1 Y _, _5 •• •It Yes,See Sidebar
H K906102 IL 2025 I 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1 G N DT13S032187283 ALTEZA ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Obrajero Garcia.Jose 12A0001568639 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 01 ,18 ,2025 12 45 ®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
2 ❑ 30 15
N 1 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction
SECTION CITATION NO. ENS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME / / ❑PM '
o N ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
25
t 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1540-Allah. Muhammad tot 275-Engelke , / D pM Workers present? ®N U2 25
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 INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
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
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L i t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
—I
CARRIER NAME Z
ADDRESS 0
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE