HomeMy WebLinkAbout2025-00023612 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003790035
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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-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00023612 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
NATIONAL ST Elgin
® ❑ RELATED ❑Y ®N 04 14 2025 DI Am ❑YES ®NO U1 -<
PRIVATE mo /day/yr 10.14 ®PM FLOW CONDITION I'n
i20 ®!MI N OE S W Grove Ave COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGED AREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Suarez. Luis. H. m0 3 /
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 1 3 SY❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
•
T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL 6 4 COM VEH 0 j$J 1 O
F- ELGIN I N I L 6O1 23 0 1 0 FIRST CONTACT 12 7_; - E
TELEPHONE
IL D 3N 1 CB51 D52L690553 unk ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unk 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N
W g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 i v 0 Dv
0 0 5 Scion TC 2010' oo-NONE ,._"j t2..-_, DUETO CRASH ❑ !g 2 x
o 13-UNDERCARRIAGE ta;l 2 FIRE 0 ® U2 C
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M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
- 6 4 COM VEH 0 ® U1 CO
L.
FIRST CONTACT 6 Y__{_O ._5 •If Yes.See Sidebar C— Elgin IL 60123 0 1 0 ED44407 IL 2025 REAR 0 Si)
IL D 0 JTKDE3B7XA0317311 State Farm ❑Y ®N RDEF .73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Hernandez Gonzalez.Octavio 0300025-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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
u 1 ® 11 1 04(14 /2025 10 14 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 03 28
N 3 0 0 CITATIONS ISSUED 0 PENDING ( 1 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME ( ( El PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
r 2 ❑ ARREST NAME AM
7 ( 1 ❑❑PM ❑Unknown work zone type
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
488-Ramos.Arely 401 - ( / ❑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
r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } __ I - r r ,.
NI (example:shuttle or charter bus):or
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier
}_---------i
es pa g pe
} trraanppoorterr-usuauyavan Type vehicle orhpass nger carj(orxample:employ} employee
0
L I I. 4. Is used or designated to transport between 9 and 15 passengers,including N
}.. ----; m - } } } g Po passen rs,includi the driver,
&7 for direct compensation(example:large van used for specific purpose):or
L i.____a____. I _ 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
0
moment.
CARRIER NAME -I
__ ADDRESS 0
1 I _Not To Scafe_f • CITY/STATE/ZIPc)
- MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
-I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
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TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gold White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE