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HomeMy WebLinkAbout2025-00012845 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 101100111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XL03738919 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ❑OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00012845 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 02 27 2025 ®AM ❑YES ®NO U1 N LYLE AVE Elgin 08:25 g PRIVATE mo /day/yr ID PM FLOW CONDITION ITT FT!MI N E S W GRANDSTAND PL COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 5 / yr Smart Passion 2014 00-NONE DUE TO CRASH ❑©1 1z _ VI 13-UNDER CARRIAGE 10 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 0 rn F 2 4 SYTM❑Y ®SNE El UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP 3 `Detraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 j$J 1 0 m ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_; __5 *lIYes.See Sidebar U1 Z 7797EL IL 2025 REAR TELEPHONE IL D WMEEK9AA4EK755080 State Farm Ins Co ❑Y ®N U2 10 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Trigo. Denise 1153164SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 NCv 0 DV /1 9 9 2 General Motor/A,ti ip 2018 00-NONE O, ' 12.._1 DUETO CRASH ❑ !g 2 x oYr 13-UNDERCARRIAGE ta,i 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i�..__4 COM VEH ❑ ® U1 CO F„ FIRST CONTACT 11 7 _, _5 •)ryes.See Sidebar C ELGIN IL 60124 B 1 0 EA69410 IL 2025 0 N M IL D 1 G KKN U LS4JZ166604 American Family Ins Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X 99 9 Hernandez.Salvador 410659223274 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DO01 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(/{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 6 10 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 02/27 /2025 08 25 0 PM in a Work Zone? ®N DIRP D co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T v 1 2 0 2 99 / / ❑PM 0 Construction Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 -a, ARREST NAME / / ❑PM ' ou ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT r 2 ❑ ARREST NAME Ej AM T / / pM 0 Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 481-Rodriguez. Hannah 602 275-Engelke / / ❑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 ` -' -' r INDICATE NORTH combination):or —I 4114 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or n i _ I 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0 �v�r ro so.r. 1 - es pa g pe by I 1 Li: } } } transporting employees In the course of their employment(example:employee X 'ry transporter-usually a van type vehicle or passenger car):or c0 __ 'is'g I - I. } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C �., for direct compensation(example:large van used for specific purpose):or O '„% _ � 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p w Pwgo?"wtt o D ., iri o. d.m1 CARRIER NAME ADDRESS T. C) CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI 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 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 White Blue 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