HomeMy WebLinkAbout2025-00013141 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 lflfl 0 100
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0G373$863
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00013141 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 02 28 2025 ®AM ❑YES ®NO U1 -<
N RANDALL RD Elgin10:27
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W AUTO MALL DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 10 0
FRONfr TOWED U1 Q
Abre o,Jerem A. Chevrolet Tahoe 2009 00-NONE „' , DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) g Y- mo yr 13-UNDER CARRIAGE 10:) 2 , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 10 <<T1
M SYTM
❑Y ❑SNE®UNK VEH. 9 AT CRASHD 9 15-OTHER
99-UNKNOWN 9 76•TOP 3 •Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,_iL 6 4 COM VEH 0 0 1 0
F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1
V Z Chicago IL 60645 0 DT18077 IL 2025 REAR
TELEPHONE
IL D 1 G N FK13529R106242 State Farm ❑Y Il N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
De Jesus Abrego Riva, Manuel 2288620SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
L RESPONDER
( XI
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 KCV 0 Dv
!2 0 0 3 Honda Civic 2020' 00-NONE ,t-1 12..-_, DUE TO CRASH ❑ C 2
o 13-UNDERCARRIAGE 10;1 2 FIRE 0 El U2 C
c
M Y SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16•TOP 3 X
❑ ❑ ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 II- 6 �' 4 COM VEH ❑ 27 Ut CO_
FIRST CONTACT 6 Y :j_O ._5 •(ryes,See Sidebar
— Evanston IL 60201 0 DF14592 IL 2025 aR 0 Si)
IL D 19XFC2F6XLE011608 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3456499SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPONDER Y u1 =
;UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 02,28 l2025 10 27 ®AM❑PM in a Work Zone? ®N DIRP >
co
I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 03 10 { ! 0 PM ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Abrego,Jeremy,A. 11-710-A 483000322 ! ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
AM U1 45
r 2 0 ARREST NAME 02 r 28 12025 11 15 [M PM 0 Unknown work zone type
x T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
483-Lynch, Miriam 500 - 1 ! 0 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 -<
i- `-----I-- --' I I IIm.iioweiI I - % INDICATE NORTH comb natbn)or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
} ~ I I I y I I® - (example:shuttle or charter bus):or C)
L A 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 co
a - C
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct com nation exam I lar a van used fors �cifice ur o ):or the driver,
Pe ( P 9 Pe p pose):or 0
' I i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
` a I I I placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME D
,, : ..... :i ..:1 ADDRESS 'O
r r -1- 1 I I 1 r
0 i. i. i. i. 4.
CITY/STATE/ZIP
o
MOTOR CARR.ID 0 Interstate 0 Intrastate
s
I I I Not To Scale I 0 Not in Comm./Govt. 0 Not in Comm./Other
%I. ------1 - % % % USDOT NO. ILCC NO. rn
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
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE