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HomeMy WebLinkAbout2025-00016069 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 lfl ID 11DIII 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003755562' u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 U1 1 U2 1 1 15 u1 1 U2 1 *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-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00016069 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 JAY ST El 04:25 ® ❑ RELATED ®Y 0 N 03 12 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION Ill FT!MI N E S W S LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 SOUSE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 8 / yr 13-UNDER CARRIAGE ©,I 0,,:0 FIRE ❑ tz STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 m M 2 6 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;il 6 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IIYes.See Sidebar U1 Z L638061 IL 2023 E TELEPHONE IL D 0 1YVFP80C845N91034 Safeway Insurance ❑Y Igl N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Ocon. Mireya 4192586-IL-PP-001 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 i v 0 Dv $ !1 9 yf 7 FRNT Honda CRV 2025 00-NONE „_, t2.._, DUE TO CRASH 0 ❑ 2 0 13-UNDER CARRIAGE I 2 FIRE ❑ ® U2 C Ti M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i. 6 i!,_4 COM VEH D ® U1 IN FIRST CONTACT 8 7 _,• _5 •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 FD83567 IL 2025 I Si)0 Z IL 0 5J6RS4H41 SL017451 Allstate ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same 974 932 536 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL) 2 6 10 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 03,12 /2025 04 25 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 11 4 23 15 03,12 ,2025 04 25 pM , ® • ❑Construction >E R 3 ❑ CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 5 z J ❑AM ❑Maintenance U2 a1 ® 11 4 ARREST NAME Benitez Ocon.Anthony 11-1204-B 476000351 03,12/2025 04 29 Igi pM SLMT o Nu ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility 0 Am t 2 ❑ ARREST NAME 03 r 12 ,2025 04 52 ®PM ❑Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30 476-Ramos.Clarissa 401 04 , 15,2025 09 00 ❑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 �____r____; _ 1 Has atioeign):htratingmorethan10,000pounds(example:truckortrucktrailer 1. -< L INDICATE NORTH pI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or C X L 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 73 w I transporter-usually a van type vehicle or passenger car):or CD L I-----}----; '""` �� n,� - •} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N S< - for direct compensation(example:large van used for specific purpose):or I I I < .l. _ t i. i t 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 ADDRESS 0 w 0 CITY/STATE/ZIP g Net To scab ) MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i. -----4 - USDOT NO. ILCC NO. rn XI Source of above Z . ❑ 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Orange Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE