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HomeMy WebLinkAbout2025-00017144 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 Hill 111 111111 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003765487` u, 1 U21 1 1 1 U, 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00017144 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m ® ❑ RELATED ❑Y ®N 03 17 2025 ❑AM ❑YES ®NO U1 -< N RANDALL RD Elgin mo /day/yr 04:11 ®PM FLOW CONDITION m _ PRIVATE �r, COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 u) Ixl— ®I MI N E O W FOX Ln WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NOV 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 9 C) 0 9 yr 13-UNDER CARRIAGE ©,I ,. Z FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 9 <<Tl M 2 SY 15-OTHER 5 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 Ii 4 COM VEH 0 Ea 1 0 I= CK59634 IL FIRST CONTACT 11 7_;—_;__5 *rives.See Sidebar U1 Z ST CHARLES IL 60174 B 1 REAR TELEPHONE IL D 0 KM8JU3AC3CU485908 Geico ❑v ign4 U2 I' 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire 99 9 Same 6142185732 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ® N 2 eu N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV 2 0 0 4 Toyota Highlander 2007 00-NONE 11_"j Qr-_, DUE TO CRASH p 2 0 13-UNDER CARRIAGE 10( I FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 1!:,„„COM VEH ❑ ® CO F,,, FIRST CONTACT 5 7 __, S •If Yes.See Sidebar 60110 0 1 BY85834 IL 2026 I0 Si)C IL D 0 JTEEW21A170039919 Illinois Insurance ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Aguilar. Francisco G01603012800 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)!{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 1 03 r 17 r2025 04 11 ®AM in a Work Zone? ®N DIRP co 1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 28 03 r ) 0 PM 0 Construction >F R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED - TIME 5 -a, ARREST NAME Fongaro.Thomas 11-601 S150700365 r r ❑❑AM ❑Maintenance SLUMT 1 ® 11 1 • 0 Utility MT a I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM Ti 2 0 11 1 ARREST NAME Fongaro.Thomas 3-414 S1507000366 03 r 17 r2025 05 32 ®PM 0 Unknown work zone type U1 55 2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? 0 Y 55 1507-Ruiz.Alondra 502 04 r 08 r2025 01 30 ®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 -' r INDICATE NORTH combination):or —I /sti BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C LiJ } (example:shuttle or charter bus):or ' I I II —"-""'�''' 3. Is designed to carry15 or fewer passengers and operated a contract carrier I O I- <-----I----; I I I I {1. - } } } transport) em to ee in the courses of their em ng p y pbyment(example:employee X I # transporter-usually a van Type vehicle or passenger car):or w` }--- ----; . ,. ,. I i } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. rn�.. l Ifor direct compensation(example:large van used for specific purpose):or O L l. i. i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires - i ---- s _____ placarding(example:placards will be displayed on the vehicle). XI iI I I I 1 1 w y CARRIER NAME Z 19J I I I ADDRESS V) Ilj I CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn Source of above z . If Yes,Name on placard 0 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 ❑No 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 0 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Silver 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: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE