HomeMy WebLinkAbout2025-00006454 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I01101100
11111 1101 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003712531
u, 1 u21 1 1 1 u, U2 7 u1 1 U2 1 u1 99 U2 99 1 11 u, 1 U2 1 *P 0119�K
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00006454 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
170 RT20 WB El08:54
® ❑ RELATED ❑Y ®N 01 30 2025 ®AM ❑YES ®NO U1
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ❑SLOW 1 cn
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 3 /
yr Honda Civic 2024 00-NONE „_ O i"_, DUE TO CRASH ❑ VIE
13-UNDER CARRIAGE 1a ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3
M 2 49 9 2
❑Y El N ®UNK VEH. AT CRASH 99-UNKNOWN I `Distraction Value 9 ALGN
FCITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST INTOONTACT 12 7_Tall_.5 ClOM VEH See Sidebar U,El 1 0
Z Elgin IL 60120 0 1 DG73654 IL 2025 mai
TELEPHONE
IL D 2HGFE2F52RH571686 Progressive El ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 929946204 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMv 0 NCV ❑DV CIRCLE NUMBER(S) U1
�2 0 0 2 Nissan Altima 2017 00-NONE ,�_"j Q�-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `OistractIon value 9 0
POINT OF 6 i1 �i" 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •IfYes,See Sidebar
H C
BARTLETT IL 60103 0 1 0 CM85802 IL 2025 I 0
IL D 3N 1 AB7AP1 HY215345 First Acceptance Ins ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same HUGIL1130319630 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 01 ,30 ,2025 08 54 ®❑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
;, 2 ❑ 11 1 03 28
! , 0 PM ❑Construction *
1
R 3 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a 1 ® 1 1 1 ARREST NAME Quinones. Rene 11-601-Ax 430000452 , r El PM SLMT
1$4 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
o N AM 50
t 2 El ARREST NAME Quinones. Rene 11-710-A 430000453 , , 0 PM ElUnknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
430-Nemt.ev.Sergey 701 272-Bajak 03 , 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 -<
` ` ' ' INDICATE NORTH combination):or p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ i.. -:. (JO _ } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
` -A- --i Not To Scale l - } } } transportingemployees in the course of their employment
pbyment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L____a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
a placarding(example:placards will be displayed on the vehicle).
CIE CIO
m
CARRIER NAME Z
__ ADDRESS 0
w
C)
CITY/STATE/ZIP g
l MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
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
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 Red
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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE