HomeMy WebLinkAbout2025-00013580 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
101101100 111 1111 11 1 11111 II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003741940
u, 1 U2 1 1 1 U116 u2 U, 1 1_12 U, 1 U2 1 1 9 U1 1 U222 *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 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00013580 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S GIFFORD ST El 07:55
® ❑ RELATED ❑Y ®N 03 02 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W D U PAG E ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR El SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 5 /
Pontiac Vibe 2005 00-NONE 11_' Q I 0DUE TO CRASH ® ❑
13-UNDER CARRIAGE 19 i : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 4 SY❑Y ®N SE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL a 4 COM VEH 0 j$J 1 O
m H ELGIN I N I L 601 20 0 1 0 FIRST CONTACT 12 7_; __5 *Ir ves.See Sidebar U1
Z DZ75235 IL 2025 E
TELEPHONE
IL D 0 5Y2SL63895Z407984 Kemper ❑Y ®N U2 19 , m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Tumwesigye.John. B. 12RA000014566 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr .
o 13-UNDER CARRIAGE 10;i :. 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
NJ -TOP 3 0 X
a ❑Y N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value
POINT OF s ) 4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO
F,,, FIRST CONTACT 6 O7 ,�=QI_5 •If Yes.See Sidebar
69099EL IL 2025 aR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTVW1 EL5NWG15693 AAA ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Hernandez. Rafael.G. AUT700799871 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) ISEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N ® 18 1 03,02 �2025 07 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
o"
2 0 28 20 1 1 ❑PM ❑Construction >F
G
Z 3 0 0 CITATIONS ISSUED 5 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Ahumuza. Louisa. P. 11-601-Ax W436-674 r r El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
t 2 0 ARREST NAME AM
7 , , ❑❑pM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 436-Lagodzinski. Brian 301 331-Ziegler , , ❑❑PM Workers present? ®N U2 30
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
0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }""�""'� Not To Seal. ' INDICATE NORTH combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver and:
- } (example:shuttle or charter bus):or
. 0
L A J 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 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 ordesignatedtotrans transport passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
rmsr � Pe ( P 9 Pe or O
i
........ t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—I
CARRIER NAME Z
nit 0
ADDRESS
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
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
T.
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Unknown . 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