HomeMy WebLinkAbout2025-00024184 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00024184 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 �l
KI M BALL ST Elgin 07:01
® ❑ RELATED ❑Y ®N 04 17 2025 ®AM ❑YES ®NO U1 -<
g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT N E S W LAWRENCE AVE COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW Cl)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) mom TOWED U1 0
NAME(LAST,FIRST,M) Perez Guerrero. Hugo 0 4 /
yr 13-UNDERCARRIAGE 101 �. 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
M 2 4 SYTM❑Y INS NE❑UNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER9 t6•TOP 3 *Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s s I,.4 COM VEH 0 El 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT OO 7_; _5 *II yes.See Sidebar Ut
Z 2109200B IL 2019 REAR
TELEPHONE
IL D 5TFAW5F19GX497647 Bristol West Ins Co ❑v igi N U2 Mr-
Ill
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same G01403376202 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 ou
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ C1
o 13-UNDER CARRIAGE 10.i :., FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 0 SPDR O
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—'1:=5 COM•I sVEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YONDER❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 0 1 2 Elgin Bridge End and Wood Rail 41 ,71 ,025 07 01 ®❑pM AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
;, 2 ® 26 2 150 DEXTER CT ELGIN IL 60120 10 15
t 3 ! / ❑PM• ❑Construction *
N 0 33 2 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z ❑AM ❑Maintenance U2
-a, ARREST NAME Perez Guerrero. Hugo 15-110 410000716 , ! El PM SLMT
o N 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
30
t 2 ARREST NAME AM
! r ❑❑PM ❑Unknown work zone type U1
El
7 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
410-DeLeon.Jessica 601 275-Engelke 51 , 01 ,025 01 30 ®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••--, , I I I I I A CMV is defined as any motor vehicle used to transport passengers or property and:
01. Has a weigh Z
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t rating more than 10,000 pounds(example:truck or truckrtrailer -<
�.__ _Y_ __l in im I. INDICATE NORTH combination):or -I
_ _ -
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i .L L , N } ,. ,. (example:shuttle or charter bus):or
im ' m,na 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
L L.___A.._.� , "I : transporting employees In the course of their employment(example:employee X
— — = a transporter-usually a van type vehicle or passenger car):or C
L •--- ----, - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
I — — — — for direct compensation(example:large van used for specific purpose):or O
L L--_-a-.... _ - t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
imi — placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME Z
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ADDRESS
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._ CITY/STATE/ZIP V)
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im - i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
' ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
----------4, - I USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
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 M
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
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE