HomeMy WebLinkAbout2025-00004979 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 0 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 08475
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El5501-S1,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00004979 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD Elgin 03:30
® ❑ RELATED ❑Y ®N 01 23 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W ABBOTT DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 0)0 Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 5 /
yr
Urbano Garnica.Jacqueline.O. Toyota Camry 2017 00-NONE „ •
Q 0 DUE TOCRASH ❑ VIE
13-UNDER CARRIAGE 10 i : 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 0 171
F 2 SYTM 4 ❑Y ®$NE❑UNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER916•TOP3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL a I, 4 COM VEH 0 0 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1
Z DA85339 IL 2025
TELEPHONE
IL D 0 4T1 BF1 FK0HU343851 State Farm ❑Y Igl N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 03382545FP13 3 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 N,Iv 0 ICv 0 DV
/2 0 0 3 BMW 330 2017 00-NONE 11_"1 Qi-O DUE TO CRASH 0 ❑ 2 x
o 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
POINT OF S i1 �i COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5
FIRST CONTACT 1 7�- -5 •If Yes.See Sidebar
Z Schaumburg IL 60193 0 1 0 ES60356 IL 2025 I 0 C
D
IL 0 WBA8D9G31 HNU62400 NONE ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same NONE BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) IDOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)+(TELEPHONE) _ (EMS) (HOSPITAL)
1 6 1 0 /
' D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
N 1 El 11 1 01 /23 /2025 03 35 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
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2 ❑ 2 99 / / ❑PM- ❑Construction
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Urbano Garnica.Jacqueline.O. 11-901-A W1512474 / / ID PM SLMT
o u 1 ® 11 1 MI CITATIONS ISSUED 0 PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0
t 2 El ARREST NAME Butler.Jaylen. L. 3-707 1512475 01/23 /2025 03 40 0 PM El Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
1512-Juarez-Huichapan.Juan 501 03 /04/2025 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
r - combination): r more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5 -<
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
o
_ } (example:shuttle or charter bus):or
1 ? I Not To Scale 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} -A- -•i
- } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or
W
L l. 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } g po passen rs,includi the driver,
o for direct compensation(example:large van used for specific purpose):or O
L L___-a..... i. < i. 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
I' pWcartling(example:placards will be displayed on the vehicle). XI
�rLr - —I
_ CARRIER NAME
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ADDRESS 0
T.
. . -.- . 1 i
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CITY/STATE/ZIP V)
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black 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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE