HomeMy WebLinkAbout2025-00013004 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003745348
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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 ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2025I 2025-00013004 VENT
ADDRESS NO. HIGHWAY or STREET NAMECITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH rn
0 0 RELATED ®Y ❑N 02 27 2025 DAM ❑YES ®NO U1 -<
VILLA ST Elgin 07:17
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W S LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED ❑PEDAL ❑EDUES ❑Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 1 FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
NAME(LAST,FIRST,M) Dionisio-Hernandez.Jesus mo Unknown Unknown 00-NONE
DUE TOCRASH ❑/ / yr 11-. 12 EN
E
13-UNDER CARRIAGE 101 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL s 4 COM VEH 0 j$J 1 0
ELGIN I L 60120 B 1 0 FIRST CONTACT 99 7_; _5 *IIYes.See&debar U1
Z NIA Unknown ' E
TELEPHONE
NA NIA ❑Y ❑N U2 53 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 52 2 NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Provena St.Joseph ❑Y ® N
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NOV ❑DV CIRCLE NUMBER(S) U1
yr Cadillac CTS 2012 00-NONE O1 0i.0 DUE TO CRASH 0 2 x
o 13-UNDER CARRIAGE 10,i I.. 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9 16.TOP 3 9 0 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i � 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y� =5 •(ryes.See Sidebar C
ELGIN IL 60120 0 1 0 EX51345 IL 2025 REAR 0 (p
IL C 0 1G6DC5E53C0147169 First Chicago Insurance C ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 1 52 2 Same ILS1025222-01 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)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 4 co
02/27 /2025 07 17 D PM AM in a Work Zone? ®N DIRP D
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 C)
2 32 99 02,27 /2025 07 20 PM
1 ® • ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
ARREST NAME 02/27/2025 07 22 ®PM
1 ® 12 4 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o u2. SECTION CITATION NO. ROAD CLEARANCE TIME El
r 2 El ARREST NAME 02/27 /2025 07 51 ®PM 0 Unknown work zone type U1 25
AM
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? D Y 25
1554-Wagener.Vincent 302 - / / ❑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
t
ADDITIONAL UNITS FORMS.
r ----r•---, , Not To Scale : 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 truckrtrailer -<
` ` '' -' r INDICATE NORTH combination):or .Z-1
Walgreens.76007VilIQ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ -:. . I j 1 I St. - } r (example:shuttle or charter bus):or 0
L A I '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
• =i' transporter-usually a van type vehicle or passenger car):or co
L L.___a____� .,� 4. Is used ordesi natedtotrans transport passengers,including N
} } } g po specific
p rs,includi the driver,
1 4. event?I for direct compensation(example:large van used fors cific purpose):or
L It1
L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
• placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME
+/E+ 1 ViIIa�St ADDRESS D
I I
rA
n
m 1 CITY/STATE/ZIP
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I j ❑ Not in Comm./Govt. Not in Comm./Other
.
U, ` r USDOT NO. ILCC NO. m
F!7 XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
Brown
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE