HomeMy WebLinkAbout2025-00009957 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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IN 1111111 101111111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003727542'
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El5501-51,500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00009957 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED PRIVATE ❑Y ®N 02 14 2025 12,—AM ❑YES ®NO U1 -<
RT20 WB Elgin mo /day/yr 06:48 ®PM FLOW CONDITION M
®20 ®/MI N ID S W STATE St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 u)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUES ❑NOV ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 /
yr 13-UNDER CARRIAGE 1a.) 2 ' 2 FIRE ❑
NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 2 rI1
F 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :il a 4 COM VEH 0 El 1 0
H 1 BARTLETT I L 60103 0 1 FIRST CONTACT 12 7': _5 *IIYes.See Sidebar U1
Z EW56160 IL 2025 Isui
TELEPHONE
IL D 0 2CNDL53F696206347 Allstate ❑Y ®N U2 1-
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Albergo.Steven.A. 975728755 3 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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Eg DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑NMv 0 NOV ❑DV
/2 0 0 1 Dodge Durango 2021 00-NONE ,�_"i 12'-_, DUE TO CRASH El (� 2
0 Yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑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 iII 8 .. .4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 ••(ryes.See Sidebar
Z SOUTH ELGIN IL 60177 0 1 EF69161 IL 2025 FIRST
C
M
IL 0 1 C4SDJCT1 MC695280 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Nevarez.Juvenal.A. 976404152 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (D001 (SEX) {SAFT) (AIR) (INJI 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 12 06 /
LOC. DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
Z
N 1 ® 11 1 21 /41 /025 06 48 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 11 03
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
a ARREST NAME / /
- u El PM
1 ® 1 1 1UtilitySLMT '
o SECTION CITATION NO. ROAD CLEARANCE TIME 0
❑CITATIONS ISSUED PENDING
t 2 0 ARREST NAME 2/ /4/ /025 06 50 0 PM 0 Unknown work zone type U1 500 AM
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - El Workers present? ❑Y 50
1507 Ruiz.Alondra 701 , / ❑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
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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
} ' 1 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 CO
< <.__-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 ...._-..:__ 11 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). ,Zmt
--I
CARRIER NAME Z
ADDRESS 0
T.
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
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black White
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE