HomeMy WebLinkAbout2025-00019834 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑ssot- 0 ®ON SCENE 1
S1,50
VEHICLE/PROPERTY ®OVER i.500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00019834 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
848 SUMMIT ST El03:16
® ❑ RELATED 0 Y ®N 03 29 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 16 to
❑ FT/MI N E S W Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 Nuv 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Gonzalez Corne o. Hugo.G. 0 1 /
yr
13-UNDERCARRIAGE 1U1 O 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 M
M 2 SYTM IN ENGAGETHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 16-TOP® ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 �i, COM VEH ❑ El 1 0
F.
ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7_; __5 *llves.SeeSidebar U1
Z 3956388B IL 2025 REAR
TELEPHONE
IL D 0 1 FT8W3B66JEB17056 State Farm ❑v I$I N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 1127218SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
§, ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EDues N Nlw 0 NOV ❑Dv
yr 10 j t2 . 2 FIRE 0 ® U2 C
o — 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 ® SPDR n
1 3 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `` *0istrac on Value 9 0 -
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF - CYT CONTACT 6 0.1.(A_`O CIOMs geeSH idebar❑ ® U1 CO
0 1 0 NONE IL 2025 REAR 0 C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1V9CD1015FV089415 Unique Insurance Company ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Perez Hernandez.Jose. F. ILC8218432 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (D051 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1ITELEPHONE) (EMS) (HOSPITAL)
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 CO 20 5 03,29 /2025 03 16 ®pm in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 03 28
N 3 0 0 CITATIONS ISSUED 0 PENDING 1 1 ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
-a, N ARREST NAME 1 / El PM '
1 ® 11 5 UtilitySLMT
o SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
0 AM
r 2 ElARREST NAME 03129 /2025 03 50 0 PM 0 Unknown work zone type U1 15
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - El Workers present? ❑Y
1547-Steele.Justin 202 , 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
l l 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` ' ' I
r INDICATE NORTH combination):or —I
IPiiitladgM.1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
f - } (example:shuttle or charter bus):or
X
A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
r I. } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L • ' ---; Not To Scalp I. 4. Is used or designated to transport between 9 and 15 passengers,including (I)
-- - - } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L L____a____. _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
I
CARRIER NAME Z
t' :( � O
_ __ ADDRESS
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CITY/STATElZIP g
MOTOR CARR.ID ❑ ta ❑
I I T ❑ NotInters in Cotemm./Gout. Not inIntrastate Comm./Other
--'---- --: - USDOT NO. ILCC NO. rn
XI
Source of above 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 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
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 ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE