HomeMy WebLinkAbout2025-00024365 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 1VI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003790142*
u, 9 u21 1 1 1 U1 2 U2 1 U199 1_12 1 u,99 U2 1 5 9 u, 1 U222 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ❑ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-000243655 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m110 S GIFFORD ST Elgin08:00
® ❑ RELATED ❑Y ®N 04 17 2025 DAM ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ FT/MI N E S W 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
Q83 DRIVER O PARKED O DRIVERLESS 0 PED p PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Unknown.0. Unknown Unknown 00-NONE 11 . 12 0OUETOCRASH ❑ VI E
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ) ! FIRE
O 0 2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 DISTRACTED 0 ]Si U2 m
9 3 Y ❑N ❑UNK VEH.SYSTEM IN
❑ ENGAGED
AT CRASH 15-OTHER
99-UNKNOWN 9 16-TOP�3 *Detraction Value _
ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;il 6 1,.4 COM VEH ❑ Ea 1
~ 0 1 0 FIRST CONTACT 2 7_i -5 *lI Yes.See Sidebar Ut 0
REAR
2 Z ' E
TELEPHONE
Unknown ❑v IN U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N❑l N 0
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 PEo 0 PEDAL 0 EWES 0 m/V 0 Ncv 0 DV
yr Dodge Ram 1500(pickup) 2019 00-NONE 11 12 _, DUE TO CRASH ❑ 2 73
Ti 13-UNDER CARRIAGE FIRE 0 ® U2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN **Distraction Value U1 9 -
POINT OF 6 I -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 10 Y :� B 'LL_S C•If O e1s.See Sidebar❑ ® C
CO
H 3769729B IL 2025 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C6SRFJT6KN725514 Country Financial ❑V ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Nunez-Hernandez. Miguel.A. P12A8333903 BAC
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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)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 18 1 04!17 l2025 10 59 ®pm in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 20 18
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING / 1 ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ID PM '
oN ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
t 2 ❑ ARREST NAMEAM
T ! / PM ❑Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
1510-Cortes. Reyna 301 331-Ziegler ! / ❑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 A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- i•____r____; I _ combination): r more than pound (example:truck ortruckrtraller 1. Has a weight rating10 000 5i -<
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I _Not To Sce/eJ } ,. ,. (example:shuttle or charter bus):or 0
L L...-A---- 1 ) } } } transporting employeened to s inthe course passengers5 or fewer thir employment(exampind e
:example:employee
transporter1 ` transporter-usually a van type vehicle or passenger car):or CO
L L....a....� �1°0°?� 1 4. Is used or designated to transport between 9 and 15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L i t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
T Z
CARRIER NAME Z
10a7s.?Gllrord?st ADDRESS 0U 1I �
oo
110?S.?Glfford?St'8 I n
- e CITY/STATE/ZIP g
3 _ MOTOR CARR.ID 0 Interstate 0 Intrastate 5
r ❑ Not in Comm./Govt. 0 Not in Comm./Other0
,....Y. .. I USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 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: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE