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HomeMy WebLinkAbout2025-00004151 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 101101100 01111011110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XOO269D11.1 u, 1 U21 3 4 1 U1 9 U2 1 U, 1 1_12 1 U, 1 U2 1 1 18 U123 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00004151 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m® ❑ RELATED PRIVATE ❑Y ®N 01 19 2025 ❑AM ❑YES ®NO U1 SOUTH ST Elgin mo /day/yr 03:50 ®PM FLOW CONDITION m 010((1x.,!MI N E S © South Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn 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 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUES ❑KIN ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0 3 / yr 11-_ 12 - 13-UNDER CARRIAGE 10l 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1 M 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 7 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i S , COM VEH 0 lE 1 C) H Z Glendale Heights I L 60139 0 1 FB98953 I L 2026 FIRST CONTACT 7 Qi :;�Q_-s *Yves.See Sidebar Ut 0 TELEPHONE IL D 0 1 G 1 PF5S97B7220227 State Farm ®Y 0 N U2 I- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Villa-Ortega. Demetria 1811125-SFP-13 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 1 9 y6r 6 Toyota Corolla 2018 00-NONE O Ql-O DUE TO CRASH ❑ (� 2 0 13-UNDER CARRIAGE 10( 1i 2 FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 POINT OF 8 i1�i" 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •If Yes.See Sidebar C Z Gilberts IL 60136 0 1 AF61597 IL 2025 I 0 Si) IL D 0 2T1 BURHEOJC000976 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 2208990-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused 0 Y°ND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 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 (19 (2025 04 00 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 30 28 ( ( ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 -a, ARREST NAME Perez-Villa. Evangelista. M. 11-1402 389005578 ( r El PM SLMT 1 ® 11 1 CITATIONS ISSUED 0 PENDING Utility o NSECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 r 2 0 ARREST NAME Perez-Villa. Evangelista. M. 3-707 389005579 01,19 (2025 03 50 0 PM El Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 389-Miller.Joshua 801 393-Gutierrez 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 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- ------I-----' ) - } INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C — _ _ _ _ _ _ — - } (example:shuttle or charter bus):or X — '"b 0°d0— 3. Is designed to carry 15 or fewer passen ers and o rated a contract carrier O - -----A i }---- - - - - — } } 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____.l 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI . . CARRIER NAME Z e —I ®8 I ADDRESS T. w Not 7b Scale I 1 1 CITY/STATE/ZIP 0 - i. i. i. i. 4. 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 . If Yes,Name on placard 0 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Blue Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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