HomeMy WebLinkAbout2025-00006663 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003715284.
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00006663 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y 0 N 01 31 2025 ®AM ❑YES ®NO U1
SUMMIT ST Elgin08:48
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W WAVERLY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 !
Ford F150 2010 00-NONE 11 Oi_, DUE TOCRASH ® ❑
13-UNDER CARRIAGE 10 i , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 ❑Y ® n is-OTHER
SYSTEM❑UNK VEH. ATCRASHD 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 . __5 *II Yes.See Sidebar U1
Z 3847893B IL 2025 E
TELEPHONE
IL D 0 1 FTEW1 E89AFD91950 First Chicago ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Elgin Fire 99 9 Same ILS107194600 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ElN 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 NOV ❑Dv
!1 9 6 5 Nissan Rogue 2011 00-NONE ,011 FR12 ;,-2 FIREOCRASH 0 D U2 C UE 2
o 13-UNDER CARRIAGE III ID
c
M 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,6•TOPO3 * X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O OistraclIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;,• 6 I,:,_ COM VEH ❑ ® U1 CO
FIRST CONTACT 3 7-'_, _5 •(ryes,See SidebarC
n ELGIN I L 60120 B 1 0 EG 12539 I L 2025 REAR 0
Z
IL D 0 JN8AS5MT3BW158496 Unique ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Elgin Fire 99 9 Same I LP3437530 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 11 ( 11 l025 08 50 ®❑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 C)
2 ❑ 2 28 1/ (1/ (025 08 55 ❑PM ❑Construction *
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ®AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Oliva Chacon. Marco.A. 6-101 436-000668 1/ ,11 l025 09 01 ❑PM ❑Utility SLMT
B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 ❑ ARREST NAME Oliva Chacon. Marco.A. 11-601-Ax 436-000669 11 '1/ (025 09 35 MPM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
436-Lagodzinski. Brian 202 272-Bajak 21 , 51 (025 01 30 0 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____; CD _ 1. Has combination):or
rating more than 10,000 pounds{(exam
ple:e le:truck or truckrtrailer -<
INDICATE NORTH P3
Nee m Seale j BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
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
transporter-usually a van type vehicle or passenger car):or lP
L 4. Is used or designated to transport between 9 and 15 passengers,including N
--- ----; summmsbeet - } } } g po passen rs,incltrdi the driver,
—— — for direct compensation(example:large van used for specific purpose):or
■ 0D
L <____a____. i } L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequires
rn
t placarding(example:placards will be displayed on the vehicle). ;p
D
CARRIER NAME Z
•
ADDRESS 0
61
C)
CITY/STATE/ZIP
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./GaA. Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
Xl
Source of above Z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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
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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
White Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO.
Redmons/Impound Lot Garage . 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