HomeMy WebLinkAbout2025-00016739 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 10111111
1 NilDRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003755636
u, 1 U21 2 4 1 U, 2 U2 1 U, 1 u2 1 U, 1 u2 1 1 15 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El5501-S1,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00016739 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l
® ❑ RELATED ®Y ❑N 03 15 2025 ❑AM ❑YES ®NO U1 -<
N SPRING ST Elgin03:15
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SUMMIT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 0
0 4 !
yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 8 m
M 2 4 ❑Y ®SNE❑UNK VEH. O ATCRASHDis-OTHER
O 99-UNKNOWN 016 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� S �'.4 COM VEH 0 j$J 1 n
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 8 (1)_; --5 *II Yes.See Sidebar U1 0
Z 3113994B IL 2025 REAR
TELEPHONE
IL D 0 1FTPX14555FB15185 Illinois Insurance ❑Y ®N U2 ni
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Rodriguez.Jose PAL 1077703-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
rg-
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 141Av 0 NCv 0 DV
!1 9 9 8 Hyundai Elantra 2007 00-NONE 0. Q!'-O DUE TO CRASH rg ❑ 2 x
0 y Yr 13-UNDER CARRIAGE 10( I E FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 6 I1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 ?A .5 •If Yes.See Sidebar
z ELGIN IL 60120 0 1 0 Q322882 IL 2025 I 0 C
IL D 0 KMHDU46D27U266836 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Carbajal. Faviola 975405172 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER® U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 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 03,15 /2025 03 15 ®AM 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 C)
v 2 2 28 03,15 ,2025 03 15 ®PM ❑Construction >E
R 3 ❑ zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Guillen Rios. Pascual 11-1427.4- 1527000294 / ! ❑PM SLMT
o N lffi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ,_,Utility
r 2 El ARREST NAME Guillen Rios. Pascual 11-601-Ax 1527-000295 031 15 ,2025 03 20 0 PM ❑Unknown work zone type U1 30
2 2 3 ❑10
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1527-Juarez.Jorge 102 360-Yucaitis 04 ,22,2025 01 30 0 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 -<
c ` -'- ' r INDICATE NORTH comWrtation)or
I 1 -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
L A �1 4.1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
a -- iy i 'u z - } } } transportingemployees In the course of their employment
pbyment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
C
sumrrgt7st eumnit'+8[ } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (/)
for direct compensation(example:large van used for specific purpose):or O
L L____a____.: OM <71
0 . — } } Y L 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires m
—� i,,,,.f,. placarding(example:placards will be displayed on the vehicle).
sumrst ��� I CARRIER NAME Z
Mg NW
I .I I I 0
ADDRESS
T.
- Not TO Scale I tJ CITY/STATE/ZIP 0
Z'le I = - MOTOR CARR.ID 0 Interstate ❑ Intrastate
I r I 0 Not in Comm./Govt. Not in Comm./Other
0 0
------ ----1 USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Black
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE