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HomeMy WebLinkAbout2025-00009370 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I01101100 !III IIIIII III III TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003728564 u, 1 U21 3 4 3 u1 2 U2 1 u, 1 u2 1 u, 1 U2 1 2 10 u1 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00009370 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ' V 0 N 02 12 2025 ®AM ❑YES ®NO U1 -< SHALES PKWY Elgin06:20 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III FT!MI N E S W E GH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0!Cu 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 2 ! yr Kia Motors Corte 2013 00-NONE 11-. Q 0 OUE TO CRASH ❑ VI E 13-UNDER CARRIAGE IE FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U 0 DISTRACTED 0 0U2 0 171 M 2 SYTM IN ENGAGE4 ❑Y ®S NE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOPO *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 ii,4 COM VEH 0 j$J 1 0 F. Palatine I L 60074 0 1 0 FIRST CONTACT 1 7_; __5 *lives.See Sidebar Ut Z ED85100 IL 2025 REAR TELEPHONE IL D 0 KNAFX4A60E5127242 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 12AU001575337 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ixv 0 DV yr Q 2 �1 Ti 13-UNDER CARRIAGE 10 j ©( 2 FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,f6•Top 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 Il, COM VEH ❑ ® U1 CO FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar n ELGINREAR IL D 0 JTDDR32T6Y0064734 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1104307SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOE)) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 06 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 3 21 ,21 l025 06 20 ®❑PM in a Work Zone? ®N DIRP co I t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 8 C) T o" 2 ❑ 2 99 + ! 0 PM, ❑Construction * 1 N 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Suarez Rodriguez. Pedro 11-902 369-002213 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 35 t 2 ARREST NAME AM T El r ❑❑PM ❑Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 369-Varga.John 302 368-Davenport 31 , 51 ,025 09 00 ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; ; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 i. <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-.�____� l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O 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 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Blue Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE