HomeMy WebLinkAbout2025-00010172 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0100 lI
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003745346
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INVESTIGATING AGENCY DAMAGE TO ANY El g500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑g501-g1,500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00010172 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 71
® ❑ RELATED PRIVATE ❑Y ®N 02 15 2025 ❑AM ❑YES ®NO U1
N STATE ST Elgin mo /day/yr 10:01 ®PM FLOW CONDITION m
10(� • COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® 1C'J!MI O E S W I-90 WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED 0 Peoa_ 0 eaves 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGED AREA(S) FROM TOWED U1 0
NUNEZ-GARCIA.JESUS.J. 0 7 / /1 9 y 1 00-NONE „ 12 , DUE TO CRASH 0 0 NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑ 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 1 3 ❑Y SYSTEM IN ENGAGED (i� OTHER 9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 9 UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�a 4 COM VEH 0 0 1 00
1. FIRST CONTACT 15 7 ;—, _5 *II Yes.See Sidebar U1
V Z AURORA IL 60506 K 1 0 REAR
TELEPHONE
IL 0 ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire 1 61 1 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
Sherman RESPONDER N ZI^
VI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!ivy 0 KCV 0 DV
/1 9 yf 8 Toyota Camry 2010' 00-NONE ,i_"1 01.-_, DUE TO CRASH 0 ❑ 2 x
o 13-UNDER CARRIAGE 10,1 I. 2 FIRE ❑ ® U2 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 POINT OF I 0
8 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Y_I-4i_ U1
COM VEH ❑ ® W
_S •IfYes,See Sidebar C 1= Bull Valley IL 60098 0 1 0 ET58973 IL 0 Si)
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IL 0 4T4BF3EK8AR043192 Unique Insurance Co ❑Y ®N RDEF X1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ILP3319586 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W 04 /
71
/ , U1 ' D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
co
N 1 ® 11 1 2/ /5/ /025 10 01 ®AM in a Work Zone? ®N o1RP D
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 28 99 2/ ,5/ /025 10 05 pM
® • ❑Construction *
Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a, ARREST NAME 2/ /5/ /025 10 08 Igi PM '
1 ® 1 2 1 0CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o NEl
AM U1
r 2 El ARREST NAME 2/ /6/ /025 02 20 pM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
1518 Versetto. Elisa 501 334-Fries / ❑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. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
< } A i N r
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
� pa 9 pe by i
} } } transportingemployees in the course of their employment(example:employee
r transportr-usually a van type vehicle or passenger car): r w
L 4. Is used or desi nated to trans rt between 9 and 15 ge ng N}-----}----; li I I. } } g po specific
rs,includi [he driver,
for direct compensation(example:large van used fors cific purpose):or
O
} } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME Z
Z
ADDRESS 0
D
Not To Scale I EigiCI
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I- -------- - USDOT NO. ILCC NO. rn
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Green.Dark
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE