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HomeMy WebLinkAbout2025-00009529 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 VI Dl DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003728467- u, 2 U2 2 4 3 U1 4 U2 U, 1 U2 U, 1 U2 5 6 U1 3 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 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 f or Tow Due To Crash El AMENDED YR 202512025-00009529 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1 N MCLEAN BLVD El In 08:28 ® ❑ RELATED ' V 0 N 02 12 2025 ❑AM El YES ®NO U1 -< g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT N E S W DEMMOND ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW Cl)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 9 ! yr Nissan Maxima 2013 00-NONE ©1. QQ , 1 DUE TOCRASH ® ❑ 13-UNDER CARRIAGE ) 2 FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m M 2 4 SYTM❑Y ®SNE El UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 t6•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH ❑ Ea 00 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Yves.See Sidebar U1 Z DX78281 IL 2025 Isui TELEPHONE IL D 0 1 N4AA5AP5DC800992 SAFEWAY INS ❑Y ®N U2 n-i 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same 3892617-I L-PP-004 3 m o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 rg- 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIUV 0 KOV 0 DV yr 12 _ C1 o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 0 U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracbonvalue U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1._5 CIO Ms See SidebarEH 0 C CO F` REAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 10 X BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 1 3 City of Elgin Damaged crossing sign 02,12 /2025 08 28 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 iii t 2 ❑ 34 150 DEXTER CT ELGIN IL 60120 19 11 ! ! ❑AM ❑Construction * Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Lopez Velasquez.Yuri.J. 11-709-A 751916 ! ! El PM SLMT o u 1 0 ig!CITATIONS ISSUED 0 PENDING Utilit o N SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑ y t 2 El ARREST NAME Lopez Velasquez.Yuri.J. 11-501-A-2 751915 02 r 12 ,2025 09 18 ®PM ❑Unknown work zone type U1 35 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 2 3 ❑ 1519-Bae2 a.Guadalupe 602 03 , 14/2025 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. 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 -< c ` -' -' r INDICATE NORTH combination):or Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X I- <.___a.._.� Demnand?st } } } 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 transporting employees In the course of their employment(example:employee P3 transporter-usually a van type vehicle or passenger car):or CO --.� N?McLean?Blvtl C -- - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to for direct compensation(example:large van used for specific purpose):or O L L--_-a-....1 % t i. i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m placarding(example:placards will be isplayed on the vehicle). xi CARRIER NAME Z ADDRESS 0 T. C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 5 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 USDOT NO. ILCC NO. m 73 Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. 71 73 m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown D Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown M Did Carrier Safety Regulations MCS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0 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 tn LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z 4 TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE