HomeMy WebLinkAbout2025-00024839 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 4 Sheets 01111101111 011011001VVI1I10�0001000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003792213
u, 9 U2 1 1 1 U1 4 U2 U,99 1_12 U,99 U2 1 4 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00024839 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
727 JAY ST Elgin02:35
® ❑ RELATED ❑Y ®N 04 20 2025 ®AM ❑YES El NO U1 -<
PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Cook 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 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!Cy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FROnrf TOWED U1 0
Unknown.0. Hummer H3 2006 00-NONE 11,• ,z DUE TOCRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ) ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 1 NI
M
9 SY 15-OTHER
9 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_i L 6 i COM VEH 0 0 1
Z 0 9 0 FF56786 IL FIRST CONTACT 1 _;REAR
_7 _5 Ves.See Sidebar U1 0
TELEPHONE
5GTDN136168144538 NIA ❑Y ❑N U2 I—
M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 SAN DOVAL.ALVARO NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr Chevrolet Avalanche 2008 00-NONE 11 12 _, DUE TO CRASH ❑ ® 1 a7
Ti 13-UNDER CARRIAGE FIRE ❑ ® U2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED C
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 ❑ ® SPDR 0
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value 9 U1 0 -
POINT OF 6 I -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 i'._ C.OM VEH D ® CO
F,,, FIRST CONTACT 9 7 _, _5 •If Yes,See Sidebar
2433917B IL 2025
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3G N FK12358G 168989 ALLSTATE ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Gasca.Julio 811461614 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 04/20 l2025 02 35 ®❑AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0
2 ❑ 9 1 15 20
1 + ! ❑PM• ❑Construction *
•
N 3 ❑ 18 1 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
o N El 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
25
r 2 ❑ ARREST NAME AM
7 , , ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1541-Wilkerson.Tondeo 401 331-Ziegler , , ❑❑PM Workers present? ®N U2 25
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
0 . ADDITIONAL UNITS FORMS.
r -- r••--, , ,pNrptrr - ; A CMV is defined as any motor vehicle used to transport passengers or property and: >` 'I I T+�11E�
-<
r combination)
1. Has a :or ht rating more than 10,000 pounds(example:truck or truck/trailer
' I INDICATE NORTH p—I
1
Not To
Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} i - } (example:shuttle or charter bus):or 0
l I Mr q 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 X
transporter-usually a van type vehicle or passenger car):or w
C
L -----}----; ,�i z - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
fi
for direct compensation(example:large van used for specific purpose):or
L L____a____� ? N _ i. i � t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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
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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue,Light Blue.Dark
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE