HomeMy WebLinkAbout2025-00011067 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003734,23
u, 9 u210 1 1 1 U110 U2 1 U199 1_12 1 U,99 U2 1 1 9 U1 1 U222 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00011067 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
WATCH ST Elgin04:55
® ❑ RELATED ❑Y ®N 02 19 2025 DAM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
/ ! FOR DAMAGEDAREA(S) FROr T TOWED U1 O
Unknown.0. Honda Civic 2007 00-NONE 11,• .12 DUE ❑ EN E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE NI
101 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 0 <
9 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 ' _
Y❑ ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Detraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 i a COM VEH 0 j$J 1 0
~ 0 9 0 FIRST CONTACT 1 7_; __5 *uYes.See Sidebar Ut
Z EC11422 IL 2025 E
TELEPHONE . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED 1 11/
2HGFA16847H506562 unk ®Y 0 N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Serna. Hector unk 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 10' 12 ( 2 FIRE ID El U2 1 C
Ti 13-UNDER CARRIAGE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 ❑ ® SPDR n
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN ••Distraction Value U1 9
POINT OF 6- 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j�',_ COM VEH ❑ ® CO
F,,, FIRST CONTACT 8 Q __,�_5 •If Yes.See Sidebar
2390592B IL 2025 REAR 0 Si)
M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTFX1 EFOCFC58318 Bristol West ❑V ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Gabriel Luis. Nicolas G01362571702 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 02,19 /2025 04 55 ®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
2 0 28 04
N 3 0 0 CITATIONS ISSUED 0 PENDING + 0 PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ❑PM '
o u ® 11 3 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
T 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 00
488-Ramos.Arely 401 - r , ❑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
A ADDITIONAL UNITS FORMS.
r ----r••--, , I . A CMV is defined as any motor vehicle used to transport passengers or property and: z
N 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }---_r----; I I r combination):or
INDICATE NORTH
L.-- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
i_ .:.. -:. J
_ } (example:shuttle or charter bus):or
X
Watch?&. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
- — — — — transporter-usually a van type vehicle or passenger car):or w
L 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 -a-___.I. . - - ' I: I I L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
1�1 I placarding(example:placards will be displayed on the vehicle). XI
Z
COiLl; I CARRIER NAME Z
ADDRESS D
MI w
i I CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I I I Not To Scale a 1 I 0 Not in Comm./Govt. Not in Comm./Other
I I I I fa - '
,_...Y._._ USDOT NO. ILCC NO. m
XI
Source of above z
. 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE