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HomeMy WebLinkAbout2025-00025109 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets ii III II IIIIII OUI 01100 011I I IIII I1110 11 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 92008 u, 1 U21 2 4 8 u1 2 U299 u, 1 u2 1 u,99 U2 99 1 15 u1 1 u2 1 *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 El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY N OVER$1,500 ❑NOT ON SCENE(DESK REPORT) N B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00025109 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n MEYER ST El In 03:04 ® ❑ RELATED ®Y 0 N 04 21 2025 12,— ❑YES ®NO U1 _ _ g PRIVATE mo /day/yr NPM FLOW CONDITION MFT!MI N E S W S ALDI N E ST COUNTY PROPERTY ❑Y N N DOORING ❑y #OF MOTOR El SLOW 1 (/) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST N N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGED AREA(S) FROr T TOWED U1 Michael,Timothy,C. 1 1 / yr 13-UNDER CARRIAGE ©,I :. 2 FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED N ❑ U2 0 (T1 M 2 SYTM 4 ❑Y NSNE❑UNK VEH. O ATCRASHD 0 99-UUNKNOWN 9 16•TOP 3 •Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;ii_6 I,.4 COM VEH 0 N 1 C) ~ ELGIN I L 60123 0 1 FIRST CONTACT 12 7 ; _5 *If Yes.See Sidebar U1 Z3020158B IL 2023 TELEPHONE IL D 0 1 GBHG31 U131157508 National General ❑Y ® I' N U2 in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Arellano. Michelle 2024882830 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES ❑NMv 0 Ncv ❑DV /1 9$6 General Motor'�ll tlp 2008 00-NONE 1o,r 12 c,_2 FIREocRASH ® U2 2 C oP. 13-UNDER CARRIAGE0 F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TtOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN I `Distraction Value 9 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'I- 6 il;,_4 COM VEH 0 N U1 CCI C FIRST CONTACT 8 QJ__,�_5 *It Yes.See Sidebar ELGIN IL 60120 0 1 AV65069 IL 2025 I 4 Si) Z n IL D 0 1 G KFK66858J235718 State Farm ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = QUINONES,OMAR 045676-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEATI (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 12 09 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y Z N 1 N 11 1 41 , 11 /025 03 04 ®AM in a Work Zone? NI N DIRP co 1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 23 28 , , ❑PM ❑Construction >F O 3 'A 3 0 xi CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 o 1 ® 11 1 ARREST NAME Michael,Timothy,C. 11-1204-B 1525000571 , / El PM SLMT 1$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility T 2 0 ARREST NAME Michael,Timothy,C. 11-601-Ax W1525000572 41 ,11 /025 03 53 N PM 0 Unknown work zone type U1 25 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1525-NavE,Oscar 601 223-Hughes 51 1 71 ,025 09 00 ❑PM N 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 INot To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer } } ' ' r INDICATE NORTH combination):or A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or I 1 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0 es pa g pe by Unit 1 - } } } transporting employees In the course of their employment(example:employee /'--.' transporter-usually a van type vehicle or passenger car):or w L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers, ng w - t } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or L L____a..... i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p \ Unit2 D T Meyer?St -cn CARRIER NAME -I J Z D ADDRESS D t0_ CCITY/STATE/ZIPng CDi.- MOTOR CARR.ID 0 Interstate 0 Intrastate 5 1 I r 1 C 0 Not in Comm./Govt. Not in Comm./Other CD 0 0 i'"Y""• USDOT NO. ILCC NO. m Source of above z . own tank)? 0 Yes 0 No 0 Unknown D Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0 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' m TRAILER 1 ❑ ❑ 0 Z ri TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE