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HomeMy WebLinkAbout2025-00009487 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 VI 1011111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0037285W u, 1 U21 3 4 3 U1 4 U2 1 U, 1 1_12 1 U1 1 U2 1 1 10 u1 4 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash El AMENDED YR 202512025-00009487 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 02 12 2025 ❑AM ❑YES N NO U1 S MCLEAN BLVD Elgin03:27 g PRIVATE mo /day/yr ®PM FLOW CONDITION m 0 !MI N E S College Green Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ® © 9 Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 0 0 7 / yr Kia Motors Co o 2020 00-NONE © 12 OUE TO CRASH ❑ EN O 13-UNDER CARRIAGE 9 I I! 2- FIRE ❑ IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 02 m M 2 SYTHER 4 ❑Y NSNEDUNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 t6-TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�6 �i COM VEH 0 j$J 1 0 1 . ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __-5 *rives.See&debar U1 ZCA55177 IL 2025 REAR TELEPHONE IL D 0 3KPA24AD1LE279655 Farmers Insurance ❑Y N N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co 99 9 Same 516682760 3 m .61'`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused El ® N 2 0 p; DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV 2 0 0 2 FR ^ NAME(LAST,FIRST,M) Corona Gomez.Juana Jeep(after 1986>}erty 2003 00-NONE al t2 c 2 DUE O CRASH rg U2 C D 2 o N 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistract Dn Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 I1:, COM VEH 0 N U1 co FIRST CONTACT 11 7� __5 •If Yes.See Sidebar F= ELGIN I L 60123 C 1 0 DC72049 I L 2025 I 0 IL D 0 1 J4G L58K73W610384 Allstate ❑Y J N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X 99 9 CORONA. RAFAEL 975813084 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m #occs y / U1 1 D 1 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 02,12 r2025 03 27 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 11 99 I r ❑PM- ❑Construction * Z 3 0 N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 aD ® 11 1 ARREST NAME Twohey. Robert. E. 11-1427-H- W1509000143 r ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility 35 r 2 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El - ❑AM Workers present? ❑Y 35 1 Woriman.Cassie 702 , r El 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 r .. 0 ADDITIONAL UNITS FORMS. r r----T----1 , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z } } ' ' I ( INDICATE NORTH col. r more than than (example:passengers ge truck ortruck/trailerdriver C 1. Has a weight rating10 000 pounds tlon)o BY ARROW 2 Is used or designed to transport more15 sse rs includingthe I (example:shuttle or charter bus):or n Not To Scare X A r <f" ` 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O t 1 Itt - } } } transporting employees in the course of their employment(example:employee73 I transporter-usually a van type vehicle or passenger car):or w IC4. Is used or designated to transport between 9 and 15 passengers,including ((I) I. } for direct compensation(example:large van used for specificpurpose):or [he driver, ` Pe ( P 9 Pe or o L 1____a____.l I t t i. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m -,Unit 7 placarding(example:placards will be displayed on the vehicle). XI f.:- D it -- —I - a �a CARRIER NAME Z I \-` O ADDRESS I ��� V) I CITY/STATE/ZIP g I - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. Not in Comm./Other ❑ o �� <s m i- -- ----, r USDOT NO. ILCC NO. m 1 XI 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 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 Blue 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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE