HomeMy WebLinkAbout2025-00009674 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 IN 111111111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003727582
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00009674 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y ❑N 02 13 2025 ❑AM ❑YES ®NO U1 -<
LARKIN AVE Elgin 02:52
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W N EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
U2 —I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
•FR ohrr TOWED U1 Q
mo
SARAT.
yr 13-UNDER CARRIAGE I FIRE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 ❑DISTRACTED 0 0 U2 al 4 M
M 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 76•TOP 3 *Distraction Value 7 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, it a �i COM VEH 0 j$J 1 0
ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_:, -__5 *II Yes.See Sidebar U1
Z FB72734 IL 2025 REAR
TELEPHONE
IL D 1 G1 PA5SH5E7177551 AMERICAN ALLIANCE ❑Y ®N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA-1033375-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 KCV 0 Dv
�y 1 9 9 5 Honda Fit 2007 00-NONE 0. Q!'O, DUE TO CRASH 0 ❑ 2
0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
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M 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 - •• •IfYes,See Sidebar
= ELGIN IL 60120 B 1 0 Q932945 IL 2025 REAR--
IL D J H MG D386775050310 DIRECT AUTO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire GOMEZ DE LA PAZ.QUINTINA PAIL001213704 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 21 ,31 /025 02 52 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
cii 2 0 25 28 21 ,31 /025 02 55 ®PM ❑Construction
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R 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
-a, ARREST NAME SARAT. FRANCISCO 11-306 S1533-000238 21 /31 /025 03 01 Igi PM SLMT
o u1 ® 11 4 CITATIONS ISSUED 0 PENDING • , 0
- Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME SARAT. FRANCISCO 6-101-A S1533-000237 21 /31 /025 03 30 0 PM 0 Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1533-Ruiz.Jose 601 360-Yucaitis 31 , 11 /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.
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 ` --I -' r INDICATE NORTH combination)or -I
itio BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or
Not To Scale I N.....m A
. A . I 3. Is desgned to carry 15 or fewer passengers and operated by a contract corner O
- } } } transporting employees In the course of their employment(example:employee
i_ i.. -:. • 1
transporter-usually a van type vehicle or passenger car):or w
C
L L.___a____J 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I. } } for direct compensation(example:large van used for speific purose):or
w
L L____a____. - - — a — — — t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
rmumwe. placarding(example:placards will be displayed on the vehicle). XI
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_1 r CARR NAME Z
ADDRESS 'n
V)
CITY/STATIEREJZIP
MOTOR CARR.ID 0 Interstate El Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - '-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ 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
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
Silver Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . 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