HomeMy WebLinkAbout2025-00019142 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
IIIIII 0011XD000 Hill 1111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV D3766696
u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00019142 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
WEST BARTLETT RD Elgin
® ❑ RELATED ®Y 0 N 03 26 2025 ❑AM ❑YES ®NO U1
PRIVATE mo /day/yr 05:54 ®PM FLOW CONDITION m
_
®10((1 !MI O E S W Gifford Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR SLOW 1 (n
Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DOSTOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2
FOR DAMAGEDAREA(S) FROM TOWED U1 0
NAME(LAST,FIRST,M) mo
/1 9 8 6 Honda Odyssey 2006 00-NONE 11 12 DUE TOCRASH ® 0 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 Ea U2 2 m
M I 2 5 ❑Y ®SNEM❑UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL a �i 4 COM VEH ❑ Ea 1 0
H 1- BARTLETT I L 60103 0 1 0 FIRST CONTACT 1 7 : __5 *lives.See Sidebar U1
ZQ582407 IL 2025 REAR
TELEPHONE
IL D 0 5FNRL38796B423266 State Farm ❑Y IlN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 GOROSTIETA. Diego 1337241SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 Dv
1 9 6 8 Mercedes-Ber'2300 2012 00-NONE .1.,-1 12..- 1 DUE TO CRASH p 2 x
o ay yr 13-UNDER CARRIAGE 10'i :., 2 FIRE ID El U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 9
POINT OF s i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 O7 ��_QL.-5 •If Yes.See Sidebar
Z St Charles IL 60174 0 1 0 BL19313 IL 2025 REAR 9 N
D
IL D 0 WDDGF8BB5CR196064 Erie Insurance ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 Bielefeld. Kristi Q101418318 BAc $
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
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 03,26 ,2025 05 54 ®pm 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 �
O 2 0 28 03 / ) 0 PM ❑Construction *
1
N 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Gorostieta Gonzalez. Raul. R. 11-601 S1547-000023 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
45
T 2ARRESTNAMEAM
7 ❑PM 0 Unknown work zone type U1
El 1 / ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 45
1547-Steele.Justin 401 05 (26,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- i--- -' -_-; INDICATE NORTH combination):or
p3
Y Not To Scale 1 ''
- iI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I N - } ,. (example:shuttle or charter bus):or 0
L 1 �1 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
transporter-usually a van type vehicle or passenger car):or w
L L____a____� l � 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
I Pe ( P 9 Pe or O
L L____a____. a _ l. i. 5. Is any vehicle used to transport anyhazardous material(HAZMA that requires
-u
— — — — — —unitzm
placarding(example:placards will be displayed on the vehicle). XI
Unit >
CARRIER NAME Z
ADDRESS 0V)
I r
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
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 ❑ No 0 Unknown M
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
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
Silver White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE