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HomeMy WebLinkAbout2025-00004522 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003700986 U, 1 U21 3 4 1 U, 8 U2 1 u, 1 U21 u, 1 U2 1 1 10 u, 13 U2 -3-1 *P0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00004522 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl ® ❑ RELATED PRIVATE ❑Y ®N 01 21 2025 ❑AM ❑YES E)NO U1 -< BIG TIMBER RD Elgin mo /day/yr 02.41 ®PM FLOW CONDITION M • E050 ®!MI N E s © North MCLEAN Blvd COUNTY PROPERTY ❑Y ® N DOORING ICI #OF MOTOR 0 SLOW 1 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 �i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 05 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Cuevas. Manuel 1 2 / yr 13-UNDER CARRIAGE } FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 05 M M 2 4 SYSTM❑Y IN NEDUNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER O9 16•TOP 3 `Distraction Value 9 ALGN • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 �i 4 COM VEH 0 j$J 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7 ; __5 *II Yes.See Sidebar U1 Z CS81617 IL 2025 REAR M TELEPHONE IL D 5YFBU4EE3CP043685 FALCON ❑Y ®N U2 13 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 0100109112-9 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r RESPONDER > m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv ❑N CIRCLE NUMBER(S) U1 v ❑Dv 9 8 9 Chevrolet Traverse 2020' 00-NONE 1�_' 12._ DUETO CRASH 0 2 x o 13-UNDER CARRIAGE I FIRE 0 ® U2 F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3 ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 ( 4 COM VEH ❑ ® U1 to FIRST CONTACT 1 7�. -5 •It Yes,See Sidebar F*. FIRST IL 60123 0 1 0 DU29578 IL 2025 REAR 0 M IL D 1 GNERFKW3U292412 STATE FARM ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 2511587-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 6 05 / F 2 4 0 1 0 m / / #OCCS D / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 01 ,21 ,2025 02 41 ®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 � o" 2 0 20 99 , , ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Cuevas. Manuel 11-709-A 1506-345 / / El PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 45 t 2 ARREST NAME AM 7 El 1 ❑❑PM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1506-Nunez. Maria 502 334-Fries 02 , 11 ,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 } } ' ' I I G I. INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer combination)or -< p0 Not To Scale i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I I - } (example:shuttle or charter bus):or C r 1 I [h. I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O a _ ' I. } } transportingemployees In the course of their employment pbyment(example:employee X I '\O( I transporter-usually a van type vehicle or passenger car):or L L.___a.._.� 4. Is used ordesi natedtotrans transport C } } } g po passengers,including the driver, N?MCLEAN?BLVD I I ` for direct compensation(example:large van used for specific purpose):or L ..i.. . - t . i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires O D — — — — — — — — — placarding(example:placards will be displayed on the vehicle). XI 1 q I ` I CARRIER NAME Z I I ADDRESS 'O I CITY/STATE/ZIP n II - MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----'Y----- - USDOT NO. ILCC NO. rn XI Source of above z . 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'; 0 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 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue White 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/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE