HomeMy WebLinkAbout2025-00023823 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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. TRAP/ '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00023823 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mN MCLEAN BLVD Elgin05:09
® ❑ RELATED ®Y 0 N 04 15 2025 ❑AM ❑YES ®NO U1 -<
_ -COUNTY PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W TODD FARM DR COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ 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
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
FRONT TOWED U1
NAME(LAST,FIRST,M) Jauregui.Steven. R. mo yr 0Chevrolet Silverado 2019 00-NONE -
DUE TO CRASH ® ❑
Q
13-UNDER CARRIAGE Q. FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0U2 00 M
M 2 5 ❑Y IN NSYSTEM❑UNK VINEH. 0 ATCRASHD 0 99-UUNKNOWN THER O9 16•TOP 3 `DistractionVatue 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF $ iI B �i 4 COM VEH 0 0 1 0
FIRST CONTACT 11 7 --_;__5 *II Yes.See Sidebar U1
Z Wonder Lake IL 60097 0 1 0 3732438E IL 2025 is
TELEPHONE
IL D 2GCVKPECXK1209491 American Family ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 410041354036 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.r5 RESPONDER 0
��, g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0
yr O 12,.Q C
o 13-UNDER CARRIAGE I f).. 2 FIRE ❑ ® U2 C
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M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistractlon value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-il�( 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y .5 •(ryes.See SidebarC
F-
. . ELGIN IL 60123 B 1 0 ER43684 IL 2025 I 0
IL D 2FMZA52255BA46389 Safeway ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 4024185-IL-PP-003 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 3 0 4 / M 2 5 B 1 0
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71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 04,15 l2025 05 09 ®pm in a Work Zone? ®N DIRP co
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)
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2 ❑ 2 99 , , ❑PM• ❑Construction
Z3 ❑ 1!>I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o ® 11 4 ARREST NAME Jauregui.Steven. R. 11-902 1506-384 , / ❑PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑ 35
Utility
r 2 ARREST NAME AM
T El r ❑❑PM El Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1506-Nunez. Maria 502 05 , 13,2025 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
i- -----------' - INDICATE NORTH combination):or more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L Not To Scale f _ ; ,. ,. (example:shuttle or charter bus):or X
< <---- -•-•; I transporting3. Is gemployees lloyeeo sl5 or fewer in the course of passengers
e erstrandoyment employee a contract
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r } transportr-usually a van type vehicle or passenger car):(example:r
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__ __ l ;l } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
r 1 m for direct compensation(example:large van used for specific purpose):or11111 O
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< <____a____. P _ i } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
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Y placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
• I ADDRESS 0V)
CITY/STATE/ZIP
I MOTOR CARR.ID ❑ Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
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Source of above z
.
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
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Form Number 0
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IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Green
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE