HomeMy WebLinkAbout2025-00007369 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 00 VU VI
IOU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003715237`
u, 9 U21 3 4 1 U1 5 U2 2 U199 1_12 1 1.11 99 U2 99 5 10 u, 3 U2 3 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1,500 ❑ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00007369 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
LARKIN AVE El In07:16
® ❑ RELATED ®Y ❑N 02 03 2025 DAM ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W N MCLEAN BLVD COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ FOR DAMAGEDAREA(S) FRO T TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 1 IE
01 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4
'a- CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I�6 ii,_ 1 0
I— O 9 FIRST CONTACT 99 7 ; COM VEH 0 Ea mai -5 *lIYes.See Sidebar U1
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
unI—
known ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 99 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0
2 0 0 6 Ford Fusion 2014 00-NONE ,._j t2..-_, DUETO CRASH 0 !g 2 73
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y iN ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
POINT OF s iI 4 COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - MI'_
FIRST CONTACT 7 Y__{_ ._5 •(ryes,See Sidebar
= Elgin IL 60120 0 1 CE11157 IL REAR C
0 Si)
D
IL D 0 3FA6P0G7XER312672 Geico ❑y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Gallegos Zacarias. Noemi 6156219831 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 02,03 �2025 08 45 ®AM 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 C)
2 ❑ 18 18
N 3 0 0 CITATIONS ISSUED 0 PENDING • + ) ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
15 ARREST NAME / / ❑PM '
o u ® 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
30
r 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
547 Homeler.William r ❑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 -<
i- }---.r----; I I I I. INDICATE or
INDICATE NORTH p3
I L BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 1 1 I Larkin?Ave i. e. (example:shuttle or charter bus):or 0
3. Is designed to car 15 or fewer passengers and operated a contract carrier O
`""A""; McLean?Blvd I I I I ` }} } transporting employees �In the course of their employment(example:employee
co
L ----------+ �r1/�r? - } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and 1 passengers,including the driver, C
1 - -413111
/� for direct compensation(example:large van used fors specific purpose):or
_ i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m a Urnt 1 G� placarding(example:placards will be isplayed on the vehicle). XI
__ D
i 7 I CARRIER NAME Z
ADDRESS 0
I I w
1
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
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
. own tank)? 0 Yes 0 No 0 Unknown
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
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
Red
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE