HomeMy WebLinkAbout2025-00025172 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 1VI
111111011100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003792224
u, 1 U21 1 4 1 U, 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$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 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00025172 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
RT20 WB Elgin 05:52
® ❑ RELATED ®Y 0 N 04 21 2025 DAM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W GRACE EXIT RAMP COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR El SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 MUSS 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 8 !
Hyundai Elantra 2017 00-NONE 11 OI_, ODE TO CRASH ® ❑
13-UNDER CARRIAGE 10 , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El0 U2 4 rn
M I 2 4 ❑Y ®N
SYSTEM
❑UNK VEH. AT CRASH D 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL 6 I,.4 COM VEH 0 0 1 O
~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 12 7 ; _-5 *U Yes.See Sidebar U1
Z 6735GI IL 2025
TELEPHONE
IL D 5N PD84LF2H H 115408 Progressive ❑Y I l N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 967646565 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 c
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑OWES ❑Nov ❑NOV ❑DV
!1 9 6 5 Toyota Camry 2004 00-NONE 11_"j t2--_, DUETO CRASH 0 2 x
o 13-UNDERCARRIAGE 101 2 FIRE El 21 U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
iII 6 i,_4 COM VEH ❑ ® CO
FIRST CONTACT 6 Y__{_O ._5 •IfYes.SeeSidebar
H Kirkland IL 60146 0 1 0 Y876660 IL 2025 REAR 0 C
M
IL D 0 4T1 BE32K64U380918 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 966308988 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 04/21 l2025 05 52 ®pm 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 �
0
1
2 ❑ 03 99 ) ! ❑PM ❑Construction *
Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
-a, ARREST NAME Canelo.Jonathan.J. 11-601-Ax (W)455-422 / ! El PM SLMT
o Nu 1 El 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
❑ 50
r 2 El ARREST NAME AM
7 1 r ❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 50
455 Halla�.Gabriel 401 , ! El 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
I1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` '' -' r INDICATE NORTH combination):or —I
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
m T,
}
A 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 X
rter-
y a van type
L ...I. I 4alsuosedordestlnatedtotransehrtbetweeicle or n9andr15r) ssen rs,induding[hedriver,
C
� %MOW } } } for direct compensation(example:large van used for specific purpose):or 0
L 1 $ • --.B._. (g t i. . i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
CARRIER NAME Z
N _ ADDRESS4- i. i. i. i. 4.
O
CITY/STATE/ZIP
O
MOTOR CARR.ID El Interstate El Intrastate
Not To Scale I O
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
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 ElYes 0 No ❑Unknown Out of Service ❑Yes ❑No Ti
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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Green
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE