HomeMy WebLinkAbout2025-00006167 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003713050'
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00006167 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
360 S BELMONT ST El 08:06
® ❑ RELATED ❑Y ®N 01 29 2025 ®AM ❑YES ®NO U1
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 5 Cl)
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS O
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
.FROM TOWED U1 Q
Nissan Rogue00-NONE
NAME(LAST,FIRST,M) Rodriguez Garcia. Lucero mo yr2015 Q 12 _ OUETOCRASH ❑
13-UNDER CARRIAGE 10 1 2 EN
FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ 0 U2 2 rr1
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-UNK15- NOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a �i 4 COM VEH ❑ j$J 1 C)
f. FIRST CONTACT 11 7__1�_-_;__5 *II Yes.See Sidebar U1 0
Z SOUTH ELGIN IL 60177 0 1 0 EL88741 IL 2025 REAR
TELEPHONE
IL D 0 KNMAT2MT3FP581537 Unique Insurance Company ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Rodriguez Garcia. Lucero ILP3437771 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 6 1 Unknown Unknown 2017 oo-NONE ,t"i 12..-_, DUETO CRASH ❑ ® 33 73
.. 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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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 1 0
POINT OF s )I 4 COM VEH ® ❑ U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR --16 I'
FIRST CONTACT 5 7_,_,-�05 •If Yes.See Sidebar C
BARTLETT IL 60103 0 1 0 99063SB IL 2025 I0 Si)
IL B 7 4DRBUC8N4HB428082 IllinoisCounties Risk Man ❑Y 123 N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 School District U-46. U46 P4-1001458-2425-01 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 05 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
Z
N 1 ® 11 1 01 /29 /2025 08 06 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 06 99 / 1 ❑PM ❑Construction *
1
R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Rodriguez Garcia. Lucero 11-705 W1538000120 / / El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
t 2 ❑ ARREST NAME AM
7 1 / pM 0 Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1538-Estrada. Leticia 700 237-Copland , / ❑❑PM Workers present? ®N U2 30
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: >
S?Belmont7St 01. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c `__ -r -' 0r INDICATE NORTH combination):or -I
Not To Scale 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. - i. e. (example:shuttle or charter bus):or 0
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
w transporter-usually a van type vehicle or passenger car):or w
L }-----}----; - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or O
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i i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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ti placarding(example:placards will be displayed on the vehicle). m,Zt
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semsaeer Ont7St - -- _1
6
, - CARRIER NAME Z
ADDRESS
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CITY/STATE/ZIP I n
® Sidewalk MOTOR CARR.ID Interstate Intrastate
I I °I ° Not in Comm./Govt. Not in Comm./Other
Ltd �
;------ --1 USDOT NO. ILCC NO. m
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Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ®No Z
Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®No 2
TRAILER VIM 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Yellow
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE