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HomeMy WebLinkAbout2025-00009932 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets Millill I01101100 VI 11111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003727555 u, 1 U21 1 1 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00009932 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 SOUTH ST Elgin ® ❑ RELATED ❑Y ®N 02 14 2025 ❑AM ❑YES El NO U1 —< PRIVATE mo /day/yr 05:28 ®PM FLOW CONDITION Ill 010 ®!MI N E s © South RANDALL Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FRO t TOWED U1 Crovetto.Jor e.A. 0 6 yr 13-UNDER CARRIAGE 101 I! 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY 15-OTHER 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI S �i COM VEH 0 Ea 1 0 F. ELGIN I L 60124 0 1 FIRST CONTACT 1 7 . -_5 *IrYes.See Sidebar U1 Z 9407088 IL 2025 Ismi TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ 6 ( 0 3GYFNBE37GS509221 American Family ❑Y Igl N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 0176692609 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused El El 2 0 p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 NMV 0 NOV 0 DV 2 0 0 5 Toyota Camry 2023 00-NONE QI 12 c 2 DIREO CRASH 0 ® U2 2 C Ti 13-UNDER CARRIAGE M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 11:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 11 7�. 5 •If Yes.See Sidebar n ELGIN n IL 60120 0 1 DS34309 IL 2025 IL D 0 4T1 K61 AK9PU755692 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Hernandez Miranda. Efrain 0969282SFP13 BAG $ 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 71 / U1 1 D / 1 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z co N 1 CD 11 1 02,14 ,2025 05 28 ®PM in a Work Zone? NJ DIRP > 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) o", T 2 ❑ 2 28 1 , ❑PM• ❑Construction * 1 Z3 ❑ 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 au 1 ® 11 1 ARREST NAME Crovetto.Jorge.A. 11-801-B S1507000356 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 0 AM 1 2 ❑ ARREST NAME 02 r 14 i2025 06 00 0 PM El Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 1507-Ruiz.Alondra 801 03 , 11 ,2025 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. 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 -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <-- . -___� 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 03 < <.__-a-_-_, , l• < <--_-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 ...._-..:_____� t 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 co 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 . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE