HomeMy WebLinkAbout2025-00021001 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 776 1 69*
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00021001 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 04 03 2025 ❑AM ❑YES E)NO U1
RT20 EB Elgin mo /day/yr 03:13 ®PM FLOW CONDITION Ill
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El6O0!MI N E S ® S State St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ 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 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST,M) q 0 3
yr
13-UNDER CARRIAGE 10 i 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rl1
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it a �i 4 COM VEH ® El 1 0
F. FIRST CONTACT 1 7_;,-_;__5 *II Yes.See Sidebar Ut
Z Chicago IL 60630 0 1 0 P1028900 IL 2026 REAR
TELEPHONE
IL A 7 4V4NC9TJ04N357181 Stassen Insurance Agency ❑Y EIN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same GRT14619B 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 98 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NOV 0 Dv
yr 12 ,_ C
Ti 13-UNDER CARRIAGE 10( E FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
8 i 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i1 6 I COM VEH D ® U1 CO
FIRST CONTACT 6 7 _, _5 •If Yes.See Sidebar
= PINGREE GROVEZ IL 60140 0 1 0 DA43517 IL 2025
. REAR
IL D 0 4T1 G 11 BKSM U046711 Safeco Insurance ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same Z5383848 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 / / F 2 4 0 1 0
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/ / #OCCS D
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/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 El 11 1 4/ //2 /25 03 13 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
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2 ❑ 28 99 I / 0 PM• ❑Construction *
4
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Sinchi Yuquilim -6
a. Marcos. M. 1101 W1530000338 / / ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME •• 0 Utility
55
r 2 ARREST NAME AM
7 / / ❑❑PM ❑Unknown work zone type ul
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 55
1530-Soto.Oscar 702 / / ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-•"--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
• i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 <""_" . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.___a__"_, , l• < <-"_"a"___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L____a____.: L L L ....__.�_ ; l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zt
` CARRIER NAME SINCHI LOGISTIC TRANSPORTATION Z
ADDRESS 4610 N KEYSTONE AVE 1 0
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, CITY/STATE/ZIP Chicago 1 I L)60630 M
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
: -Y- --4 ; : : Y- ; ; ; ; 54023 USDOT NO. 25 ILCC NO. m
XI
Source of above z
. 0 Yes No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ®No 7
MCS ❑Yes 0 No ❑Unknown Out of Service ❑Yes ®No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAEP 0 Yes ®No 2
TRAILER VIN 1 1 G RAP0624J K278985 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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 48 ft. 2 ft. Z
Green White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES 2
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE LOAD TYPE