HomeMy WebLinkAbout2025-00009471 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 10 Sheets 01111101111
101101100
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ID$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00009471 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
POPLAR CREEK DR El In02:14
® ❑ RELATED ®Y 0 N 02 12 2025 12,— ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION Ill
•FT N E S W HACKBERRYCT COUNTY PROPERTY :IY ® N DOORING ❑y #OF MOTOR 0 SLOW 5 Cl)
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 Mao TOWED U1 0
y NAME(LAST,FIRST,M) mo yr
Adan Gavina.Cherrlyn Acura TLX 2023 00-NONE „. (2) , DUE TO CRASH 0
13-UNDER CARRIAGE FIRE ❑ Egi
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U VI E
O DISTRACTED ❑ 0U2 2 rr1
F 2 4 SY❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s :i1 s �i,4 COM VEH 0 j$J 5 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1
Z DU17751 IL 2025 E
TELEPHONE
IL D 0 19UDE4H39PA027308 Bristol West ❑Y ®N U2 ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Adan-Mendiola.Santiago G01562228900 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
m (i,{ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑
/1 9 5 8 International GtlaCE34 2016 00-NONE i1_"j t2--_, DUE TO CRASH ❑ ® 33 �7
o 13-UNDER CARRIAGE 10'i :., 2 FIRE ❑ ® U2 C
y yr
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O1 6 l;, 4 COM VEH I$I ❑ U1 CO
,,, FIRST CONTACT 7 O7 �_ ==Q�._5 •It Yes.See Sidebar
ELGINZ IL 60123 0 1 0 834095B IL 2025 izEAR 0Si)
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IL B 7 4DRBUC8NOGB165104 Alliant Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 SCHOOL DISTRICT U-46 P41001458242501 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (D00i (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 7 06 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 ® 11 1 2/ /2/ /025 02 14 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 11 28 / / ❑PM• ❑Construction *
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 1 1 1 ARREST NAME Adan Gavina.Cherrlyn 11-601 1543000077 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
El AM
t 2 El ARREST NAME 2/ /2/ /025 03 15 ®PM El Unknown work zone type U1 ZO
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 20
1543-Sturgeon. Kyle 300 272-Bajak 3/ / 5/ /025 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
Not To Scale ` -<
1 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
` ` -'- ' r INDICATE NORTH comWrtation)or p0
i90 r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N _ (example:shuttle or charter bus):or
= 3. Is desgned to carry 15 or fewer passengers and operated
�rated a contract carrier O
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I. I- I- transporting employees In the course of their employment(example:employee � X
Nac
°ery7Ct transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l --' l C
4. Isusedordesinatedtotrans rtbetween9and15passengers,includingthedriver,
1 1 } } } for direct compensation(examp large van used for speific purose):or 0
L._--a____. — — — — C - L i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
71
I w : • placarding(example:placards will be displayed on the vehicle). X/
2
_ CARRIER NAME Z
r r f -: 4, i r :- :- :-- ADDRESS
T.
j CITY/STATE/ZIP I 0
g
MOTOR CARR.ID 0 Interstate El 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
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown E
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 ®No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Yellow
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE