HomeMy WebLinkAbout2025-00010395 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 01101100 lfl 11011110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037.5656!
u, 9 U2 1 1 1 u1 2 uz U,99 u2 U,99 U2 1 5 9 U1 1 U221 *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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00010395 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
920 HIAWATHA DR El00:12
® ❑ RELATED ❑Y ®N 02 17 2025 ®AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ /
• T FOR DAMAGEDAREA(S) FROM�TOWED U1 0
Unknown.0. Unknown Unknown 00-NONE 0 >2 >,/DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,Ii_S Ii,_ 1
I— 0 9 FIRST CONTACT 7_12 : COM VEH 0 Ea
_5 *lIVes.See&debar U1 0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
I—
unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0 N
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NCv 0 Dv
yr Mitsubishi LANCER 2017 oo-NONE 1(-i 12..- , DUE TO CRASH ❑ !1 2 73
o _ 13-UNDER CARRIAGE 10.i (, 2 FIRE ❑ El
C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TOP 3 9 9
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN O *Oistrac on Value
POINT OF 8 j� 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S 1' COM VEH D ® CO
F,,, FIRST CONTACT 5 7�_ _OS *If Yes,See Sidebar
AK38905 IL 2019 REAR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
JA32U2FU5H0009086 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Lopez.Queren E368055E0313 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(ADDRESS)r(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 3 Albiniak.Joan. E. Mail Box 02,17 /2025 00 12 ®❑AM
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
;, 2 ❑ 40 3 930 HIAWATHA DR ELGIN IL 60120 20 28 , / PM
❑ • ❑Construction *
7
Z 3 ❑ ❑CITATIONS ISSUED ID PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
—a ARREST NAME / / ❑PM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
, •7
•
30
r 2 ARREST NAME AM
7 1 r ❑❑PM El Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1532-Hernandez. Daniel 201 r , ❑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.
.. .. , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Yt1M.HIAWA'R1A?D0. • 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }----r----; : } combination):or p0
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale I - (example:shuttle or charter bus):or
( P ) X
-1 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
L -------i !�
} } } transporting employee In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or
CO
L1111 4. Is used or desi nated to trans rt between 9 and 15 ge ng C}--- ----; } } } g Po pafic rs, or i [he driver,
, for direct compensation(example:large van used for specific purpose):or O
__ i. < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). m
A
97>J'�HWNArHA7Dri ■. , CARRIER NAME Z
•OCAA,
ADDRESS D
to
. CITY/STATEJZIP o
.. - i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
l I r l . ❑ Not in Comm./Govt. Not in Comm./Other
❑
�I. ------1 USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE