HomeMy WebLinkAbout2025-00001273 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑g501-g1,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00001273 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH r7
N STATE ST El In 05:57
® ❑ RELATED ❑Y ®N 01 06 2025 ❑AM ❑YES ®NO U1 —<
g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W MOUNTAIN ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS PED ❑PEDAL 0 EDUCE ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C)
TOWED U1
FOR DAMAGEDAREA(S) mom TOWED
Canales. Rodolfo 1 2
yr 13-UNDER CARRIAGE •101 ! 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<Tl
M SYSTEM IN ENGAGED OTHER 9 16.TOP 3 _
❑Y El N ❑UNK VEH. AT CRASH 9 UNKNOWN 5 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 �i COM VEH 0 0 1 I . ELGIN IL 60120 K FIRST CONTACT 15 7 ; _5 *II Yes.See Sidebar U1 0
2
REAR
2 Z
TELEPHONE
IL 0 Unknown ❑v ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Unknown 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER eV
Provena St.Joseph ❑Y ® N
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NOV 0 NOV ❑DV
1 9 6 1 Honda Passport 2021 00-NONE 0. Q!•-O DUE TO CRASH ❑ El 2 x
0 13-UNDER CARRIAGE 19( I 2 FIRE ❑ ® U2 C
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 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:, COM VEH 0 ® U1 CO
FIRST CONTACT 11 7� 5 •If Yes.See Sidebar
H ELGIN z IL 60123 0 1 EC52979 IL 2025 AR 4 N
M
IL A 7 5FNYF8H96MB041484 UNKNOWN ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same UNKOWN BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 6 09 / F 2 4 0 1
m
/ / #OCCS D
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/ / UI ' D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 11 ,J2 /25 05 57 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YE$Check One below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o", 2 2 18 11 ,12 ,25 05 57 PM
® • ❑Construction >F
Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a ARREST NAME 11 //2 /25 06 01 Igi PM '
1 12 1 ElUtility
0 CITATIONS ISSUED ❑PENDING SLMT
o, N ®
SECTION CITATION NO. ROAD CLEARANCE TIME AM
t 2 El ARREST NAME 11 I J2 /25 08 41 ®pM ❑Unknown work zone type U1 30
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
1525-NavE.Oscar 601 - , / ❑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
CI ADDITIONAL UNITS FORMS.
r -- r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- --I-----; N
Not To Scale combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
NN 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
N. \ } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or X
-- -- N N Al - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
N
for direct compensation(example:large van used for specific purpose):or O
} } } . 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
\ 6� placarding(example:placards will be displayed on the vehicle). ;p
D
<.`j - CARRIER NAME
/ \ __ ADDRESS 'O
D
/ N ♦ CITY/STATE/ZIP 0
\ - i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I . 1 • ❑ Not in Comm./Govt. Not in Comm./Other
❑ 00
--- --1 - USDOT NO. ILCC NO. C
XI
Source of above 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE