HomeMy WebLinkAbout2025-00012481 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003/37709*
u1 1 u21 2 4 1 U1 2 U299 u1 1 U2 1 u199 U2 99 1 10 u, 3 U2 1 *P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 15
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00012481 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
N STATE ST Elgin 05:09
® ❑ RELATED ' ' 0 N 02 25 2025 12,— ❑YES ®NO U1
PRIVATE mo /day/yr ®PM FLOW CONDITION M
•
1 O /MI N E S W Washington St COUNTY PROPERTY ❑Y 2�1 N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
® g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZ1 N 51 FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FRONT TOWED U1 O
Castillo.Carmen. M. Honda CRV 2014 00-NONE ,, 12 DUE TOCRASH ❑ VI
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED THER ® ❑ U2 2 171
F 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_;iI,6-�i 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 1 7 _;__5 *If Yes.See Sidebar Ut
Z CARPENTERSVILLE IL 60110 0 1 0 CF16939 IL 2021 REAR
TELEPHONE
IL 0 2HKRM4H30EH694894 Unique Insurance Company ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Castillo. Richard. D. I LP3430122 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑ ivy 0 Ncv ❑ CIRCLE NUMBER(S) U1
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/2 Yr 0 0 7 Lexus IS300 2016 00-NONE ,u;� t2 ,,-2 FIRE DUE D CRASH ❑❑ ® U2 2 C
o 13-UNDER CARRIAGE
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 911,6•TtOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'i��j 6 i;, COM VEH ❑ ® u1CO
F,,, kg.' -5 *If Yes.See Sidebar C
Z SOUTH ELGIN IL 60177 0 1 0 ER16553 IL 2025 REAR 4 Si)
M
IL D 0 JTHCM1 D26G5008814 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
BETANCOURT.WILLIAM 989051040 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(+(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 04 /
/ / UI 2 D:A
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 02/25 /2025 05 09 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 n
T
0
2 0 2 28 / / ❑PM• ❑Construction
" 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Castillo.Carmen. M. 11-601-Ax W1525000550 / / ❑PM SLMT
S' N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
El AM
t 2 0 ARREST NAME 02/25 /2025 05 47 ®PM El Unknown work zone type U1 35
o' T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
0 Y 35
1525-NavE.Oscar 601 - / / ❑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.
0IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
.. .. , \ 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 T.
INDICATE NORTH P1
Not To Scale BY ARROW o(cc Is unsetiod or designed to transport more than 15 passengers including the driver
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\ \ _ (example:shuttle or charter bus):or
r r r X
3 Is designed to carry 15 or fewer passengers operateda carrier I 0
I- .-----I----; \ - . . . transporting employees in the course of their employment(example:employee
rie
\ k.,<' transporter-usually a van type vehicle or passenger car): r
L -----}----, } 1.; - } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or 0
L L____a____.I \44►, \ t i. i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
\ placarding(example:placards will be displayed on the vehicle). D
11111§110%. CARRIER NAME Z
/ \ \ _ 1 ADDRESS 0\ T.
\ CITY/STATE/ZIP 0
\ C
\ i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
F
FJ1
\ ❑ NotinComm./G . NotinComm. er
USDOT NO. ILCC NO. m
XI
Source of above 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
71
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
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE