HomeMy WebLinkAbout2025-00021896 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 000 lI 10111110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XoO3778322'
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00021896 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
ST CHARLES ST Elgin03:28
® ❑ RELATED ®Y 0 N 04 07 2025 ❑AM ❑YES ®NO U1
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑Mlles ❑NIIv ❑ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 6 !
yr 13-UNDER CARRIAGE lE
101 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 016 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� 6 �'.4 COM VEH ❑ Ea 1 n
" I .
Elk Grove IL 60007 0 1 0 FIRST CONTACT 9 O7 _; __5 *If Yes.See Sidebar U1 0
Z DY86950 IL 2025 REAR
TELEPHONE
IL A 7 JTDKN3DU6D0337061 Progressive ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
PAPCH EN KO.VASYL 990373824 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 ivy 0 KCV 0 Dv
'1 9 6 6 Nissan Sentra 2007 00-NONE 11_"1 Q1:O DUE TO CRASH 0 ❑ 2 x
0day Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 1:, COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7�.REAR-5 •If Yes.See Sidebar
n ELGIN
D IL 60123 0 1 0 EA24296 IL 2024
IL 0 3N1AB61EX7L716755 Falcon ❑Y J N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Estrada.Julianna.J. 01000127909-3 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
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u N 1 El 11 1 41 ,12 !25 03 2g ®PM AM in a Work Zone? NJ DIRP D
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1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
0 T
2 ❑ 2 28 1 , ❑PM- ❑Construction X
Z 3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a LUFERENKO. MYKHAILO 11-601 W476000358 / ! PM
-, ® 11 1 -ARREST NAME ❑
o U �!CITATIONS ISSUED 0 PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM' ❑
I 2 El ARREST NAME Manriquez Lopez. Eulogio 6-303-A 476000359 41 ,12 ,25 04 13 ®PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos.Clarissa 401 51 , 01 ,025 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 truckrtrailer -<
COINDICATE NORTH —I
p0
IF BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
' r r r �
L L AL 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
I. } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or03
• C
i. ...I. - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
for direct compensation(example:large van used for specific purpose):or O
L a t i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
a.e7111 i placarding(example:placards will be displayed on the vehicle). XI
—1
—0r - - -
CARRIER NAME Z
ADDRESS
0
V)
C)
Not To Scale I MOTOR CARR.ID 0 Interstate El Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
�" --- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue 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 DUETO TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE