HomeMy WebLinkAbout2025-00003929 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a69'S49a
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00003929 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 01 18 2025 ❑AM YES ®NO U1 -<
LARKIN AVE Elgin03:12
_ _ g PRIVATE mo /day/yr N PM FLOW CONDITION IT1
FT!MI N E S W MARKET ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 NW 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 4 /
yr 13-UNDER CARRIAGE 10 i 2 FIRE 0 M
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 El ® n is-OTHER
SYSTEM
❑UNK VEH. ATCRASHD 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 it 6 �i COM VEH 0 Ea 1 0
F• Elgin IL 60123 0 1 0 FIRST CONTACT 11 7_;1 __5 *0Yes.See Sidebar U1
Z 9 E787981 IL 2025 REAR
TELEPHONE
IL D 1C4NJPBA2FD328796 State Farm ❑Y ICI N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 2139395-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
p; DRIVER ❑ PARKED 0 ORIVERLESS 0 PED 0 PEDAL 0 EWES 0 raw
yr 10 I 12 ` E FIRE ❑ N U2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOPO3 * X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN 0istractlon value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 6 1.,( 4 COM VEH El U1 CO
FIRST CONTACT 2 7-'_, _5 •)ryes.See Sidebar
= ELGIN IL 60120 0 1 0 ER16591 IL 2025 REAR
C
M
IL D 5NPD84LFOKH480502 NIA ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same NIA BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (D013) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 04 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 01 ,18 ,2025 03 12 0 AM 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 C)
v 2 ❑ 2 99 01,18 ,2025 03 19 ®PM ❑Construction *
R 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Gonzalez. Fabian. L. 11-1205 1532000443 01,18 r2025 03 23 Igi pM• • El SLMT
El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME Dungey. Laryssa. D. 3-707 1532000445 01,18 ,2025 03 15 N PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1532-Hernandez. Daniel 602 02 , 11 ,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 Bator vehicle used to transport passengers or property and: Z
1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' -' r INDICATE NORTH combination):or
aiuucerooremat�veauvwwE BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
} - } (example:shuttle or charter bus):or X
' A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; t 1 �— - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or
L L____a____. 2 _ I. 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). XI
...............
CARRIER NAME —1Z
__ ADDRESS 0
w
0 uwivrMve. n
CITY/STATE/ZIP 0
Not 7b Sews I _ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Gout. 0 Not in Comm./Other
�I. - ----1 - USDOT NO. ILCC NO. Tn
XI
Source of above z
. ❑ Yes II No ❑ Unknown 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 ❑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' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red 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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE