HomeMy WebLinkAbout2025-00013693 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II I 111 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003743585
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 10
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00013693 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1
® ❑ RELATED ❑Y ®N 03 02 2025 ❑AM ❑YES ®NO U1
N LIBERTY ST Elgin05:51
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
g15 ®0 !MI N E S W Cooper Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
p Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EouES ❑Nuv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
0 4 / yr
Chevrolet Tahoe 2007 00-NONE DUE TO CRASH 0 E 11... 12 _
13-UNDER CARRIAGE 10 i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 3 <<T1
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 ij B �i 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_;- -_5 *IrYes.See Sidebar Ut
Z CJ60694 IL 2025 E
TELEPHONE
IL 1 G N FK13087J370842 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR M
Same 12AU001472532 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑!My 0 Ncv ❑Dv
!1 9 9 0 yr Hyundai Sonata 2021 00-NONE 13-UNDER CARRIAGE Q.1 12 2 FIREocRASH ® U2 2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 7 -5 •If Yes,See Sidebar
n ELGIN IL 60120 0 1 0 AT29585 IL 2025 I 0
Z Sn
IL D 5NPEG4JA2MH115885 Geico ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 6163307504 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOOi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 09 /
7/
/ / UI 3 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 03,02 /2025 05 51 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 28 20
N 1 3 ❑ ]$I CITATIONS ISSUED El PENDING ! 1 ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Aranda-Saldana. Marcos 11-601 1550000010 / / ID PM SLMT
o U 1 ® 11 1 ISI CITATIONS ISSUED 0 PENDINGTIME 0• Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 30
t 2 El ARREST NAME Aranda-Saldana. Marcos 11-709-A 1550000011 / / pM Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1550-Camiacho.Oscar 201 04 /08,2025 01 30 ®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.
Keep?Ave. .
r ----r•---, , — — — : A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
combination):or —I
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I } (example:shuttle or charter bus):or 0
N.7 Iberh/'sf. 3. Is designed to carry15 or fewer passengers and operated I a contract carrier O
` A i fff!!lfff!!!- ---- ,
}- } } transporting employee � �In the course of their employment(example:employee X
or c0
< ...l. 1 1 I _ I. } C
transporter. sedordesgnatedtotransportbetweelly a van type vehicle or n9a d15enger rprssen rs,includingthedriver. y
t5 I } } for direct compensation(examp large van used for specific purpose):or
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L L--_-a-.... 1 Wit
i iany m
L 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m;p
w, ? - -- CARRIER NAME Z
t 1 I ` ADDRESS D
CITY/STATE/ZIP 00
Cooper?Ave MOTOR CARR.ID 0 Interstate ❑ Intrastate
. . T . I I 0 Not in Comm./Govt. 0 Not in Comm./Other 00
-- --; 1 I I [ Not To Scale
USDOT NO. ILCC NO. C
m
xi
Source of above z
. • m
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 White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 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