HomeMy WebLinkAbout2025-00008307 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 00 10
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0G37185 5
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00008307 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mLINCOLN AVE Elgin
® ❑ RELATED ❑Y ®N 02 07 2025 DAM ❑YES El NO U1 -<
PRIVATE mo /day/yr 06:53 ®PM FLOW CONDITION m
E180 ®!MI N E S ® Dundee Ave COUNTY PROPERTY ElY 21 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
tg DRIVER p PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 8
, FOR DAMAGEDAREA(S) FROM TOWED U1
Unknown.0. Unknown Unknown 00-NONE 11 . 12 DUE TOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 _
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
6 I 4
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 Ii COM VEH 0 ZgJ 2 O
~ 0 9 0 FIRST CONTACT 1 7_;mai -5 *If Yes.See Sidebar Ut
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 111
Unknown ❑Y ®N U2 I-
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
yr
o 13-UNDER CARRIAGE 10;1 !. 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
NJ -TOP 3 9 X
a ❑Y N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
:4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
6 1�'`_ COM VEH ❑ ®
F,,, FIRST CONTACT 7 O6 7 -5 •If Yes.See Sidebar C
EJ32625 IL REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C3CDFEB5ED747919 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Herrejon Soto.Jose.O. 987379397 BAC
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)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 02,07 �2025 06 53 ®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 0 20 28
N 3 0 ❑CITATIONS ISSUED 0 PENDING • + ) ❑PM- ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
-a, ARREST NAME / / El PM '
1 ® 1 1 1 UtilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME ❑
❑CITATIONS ISSUED PENDING
T 2 0 ARREST NAME 02 r 07 12025 07 36 ®PM El Unknown work zone type U1 30 0 AM
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 30
432 Obenauf. Matthew 102 / / ❑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 truckrtrailer -<
' ® r INDICATE NORTH combination):or p0
/ Not To were j BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
/ / - (example:shuttle or charter bus):or 0
X
/448,ZO#441#fiwe / r 3. Is desgned to carry 15 or fewer passen ers and o rated a contract carrier O
l / trarnisppoorterg-usuauyavan Type vehicle or ppa s nger caM(o xample:employ w
} } } ee0, , c? I. } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
__ ____ / for direct compensation(example:large van used for specific purpose):or
_
• , urlael7Ave wr
7 ; um.' < i L 5. Is any vehicle used to transport anym
/ / placarding(example:placards will be displayed
material(HAZMAT)that requires isplayed on the vehicle). ;p
/ / . 1
/ / CARRIER NAME Z
/ / - ADDRESS0
/ / �
/ // CITY/STATE/ZIP 0
/ / _ 1 MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
;....Y_ _..; - 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 spit 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
to
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
White Black
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 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