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HomeMy WebLinkAbout2025-00004094 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H IM OUI 00110001111111110000000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xoo369a47 u, 1 U2 1 1 1 U, 2 U2 1 U, 1 1_12 U, 1 U2 1 3 9 U1 1 U221 *P 0119* 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 El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00004094 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 684 FOREST AVE Elgin06:49 ® ❑ RELATED ❑Y ®N 01 19 2025 ®AM ❑YES El NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 21 (n ❑ 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 Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 5 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn M 2 8 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 ii,4 COM VEH 0 Ea 1 00 ~ ELGIN N I L 60123 0 1 FIRST CONTACT 1 7_;1 __5 *lI Yes.See Sidebar U1 Z AR39418 IL 2025 REAR TELEPHONE IL D 1 FM5K8GC6LGC76687 Allstate ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 802 491 741 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 ou ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Ncv 0 Dv yr 1t.1 12 -1 ❑ ® 1 ,� o _ 13-UNDER CARRIAGE 10;1 c. 2 FIRE ❑ ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 ® SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value U1 0 - POINT OF s I a N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 COM VEH ❑ ® CO F,,, FIRST CONTACT 7 O7 ��_Q I,._5 •If Yes.See Sidebar 1543PATA IL 2025 REAR 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 TD307900 Unknown ❑V ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Barber.Yvonne. N. Unknown BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOG) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 6 1 2 / F 2 5 0 1 U2 996 m / / #OCCS > / / UI 2 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 01 /19 /2025 06 49 ®❑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 ,, 0 2 41 99 1 / ❑PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a1 ® 11 1 ARREST NAME Verastegui.Jose. L. 11-601 414-994 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 20 r 2 ❑ ARREST NAME AM T / / ❑❑PM ❑Unknown work zone type U1 ,fix2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 20 414-Lara. Saul 202 02 , 18/2025 09 00 ❑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 -< ` ` -' -' r INDICATE NORTH combination):or —I A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverA i I C - (example:shuttle or charter bus):or 0 3. Is designed to carry15 or fewer passengers and operated a contract carrier O Not To Scale I - ,} } . transporting employee in the course of their employment(example:employee 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 O L ' ___- Until- _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M u rz placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z _ ADDRESS V) CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate El 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 . ❑ Yes 0 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 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Arties/Unknown . 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