HomeMy WebLinkAbout2025-00024215 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 VI fl 0100 III
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003790105
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00024215 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l
® ❑ RELATED ®Y ❑N 04 17 2025 ®AM ❑YES ®NO U1
HIAWATHA DR Elgin10:25
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FTlMI N E S W FORD AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
NAME(LAST,FIRST,M) Almanza.Albert mu /
13-UNDER CARRIAGE 10 i , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 <<n
M 2 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI B 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 . __5 *u Yes.See Sidebar Ut
Z ED73764 IL 2025 E
TELEPHONE
IL 0 5N1AR2MM6DC624498 State Farm ❑Y Il N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Almanza.Claudia.T. 2021894-sfp-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m Ei{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 Nuv 0 NCv 0 Dv
/1 9 8 8 Nissan Rogue 2015 00-NONE 11-.' 12..-_, DUE TO CRASH rg D 2
0 13-UNDER CARRIAGE I 2 FIRE ❑ El U2 C
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F 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16•TOP 3 X
❑Y lYi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si S i.�,_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 9 7 -5 C.
If Yes.See Sidebar C
Z Carpersville IL B 1 0 EQ88320 IL 2025 I g fp
D
0 5N1AT2MK9FC794289 Kemper ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 99 9 Gutierrez. Roberto 12au001529190 SAC E
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)((A.DDRESS)(!TELEPHONE) (EMS) (HOSPITAL)
2 3 05 / 2 6 0 1
m
/ / S#OCC D
X)
/ / U1 1 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 4 04,17 l2025 10 25 ®❑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 1 n
T
5
2 ❑ 2 18 , ! ❑PM ❑Construction X
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Almanza.Albert 11-901-A 324-1449 / / El PM SLMT
MI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N Di AM 30
t 2 ❑ ARREST NAME Rojas Vazquez.Yesica 6-101 324-1450 , / PM ElUnknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
324-Phillos.James 201 05 / 13,2025 09 00 ❑PM Workers present? ®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 -<
1
CI ;. INDICATE NORTH p1
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driver
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I- _ } (example:shuttle or charter bus):or
/be I Lilowdho , , , T,
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3. Is designed to carry15 or fewer passengers and operated a contract carrier O
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} } } transporting employee in the course of their employment(example:employee I °
Fore q-- transporter-usually a van type vehicle or passenger car):or CO
iiirjL L.__-a._ - t 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
i �.r172 } } •
for direct compensation(example:large van used for speific,�:^,,^;—J, purpose):or
L L.__-a..... - l. i. < i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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Ili placarding(example:placards will be displayed on the vehicle). :0
LI., _ _. —1
Ford — Feb , , , , , CARRIER NAME Z
_ __ ADDRESS 'O
V)
Howl I twine 0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. • m
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
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Bronze Red
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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE