HomeMy WebLinkAbout2025-00022998 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 101101100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003190219
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 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$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00022998 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 04 12 2025 ®AM ❑YES ®NO U1
JEFFERSON AVE Elgin05:30
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
10 !MI N E S Douglas Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
® ® g Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER t] PARKED O DRIVERLESS 0 PED CI PEDAL 0 EOUES 0 RIAU 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRO r TOWED U1 Q
NAME(LAST,FIRST,M) Dubon Alvanez. Luis. F. m0 0 /1
13-UNDER CARRIAGE 10 , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY4 ®Y ID ❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL e 4 COM VEH 0 El 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 12 7_: _5 *Irves.See Sidebar U1
Z EV20807 IL 2025 REAR
TELEPHONE
IL D 1 G 11 C5SL4FF129826 None ❑Y ®N U2 19 . m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Alvanez. Keyelin None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr
o 13-UNDER CARRIAGE 10( l FIRE ❑ El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 X
a
❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
POINT OF 8 -4ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 '+�.5 COM•IesVSee Sidebar ® CO
H FA50867 IL 2025 I 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
KMHWF35H25A172634 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Ramirez. David 3541150SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N ® 18 1 04,12 l2025 05 30 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 19 17 / / 0 PM ❑Construction *
Z3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Dubon Alvanez. Luis. F. 11-601 752822 / ! ❑PM SLMT
o U 1 ® 11 1 ISSUED0 Utility
u CITATIONS PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑
r 2 ❑ ARREST NAME Dubon Alvanez. Luis. F. 6-101 752820 04 t 12 ,2025 06 20 [M PM El Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
498-Johnson.Andrew 102 04 ,28,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed totrann ortmorethan15 C
Q I - } (example:shuttle or charter bus):or passengers including the driver 0
N P3 I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
-- - } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
__ __ J $I `� 1 } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
Jefferson?Ave for direct compensation(example:large van used for specific purpose):or 0
< .I. _ {�.-_��' _ L } } } t 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires
li IIym
�, placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
I Not Tb Scab 1 ADDRESS D
w
CITY/STATE/ZIP 0
- i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - % % % USDOT NO. ILCC NO. rTt
XI
Source of above 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE