HomeMy WebLinkAbout2025-00025972 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003797774
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00025972 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 04 24 2025 ❑AM ❑YES ®NO U1 -<
BENT ST Elgin08:58
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W S LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
QT3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 lacv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1
NAME(LAST,FIRST,M) Zuniga. Emely.G. 1 2 /
yr 13-UNDER CARRIAGE I l: FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 Ea U2 0 m
F 2 4 El ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN THER 9 16-TOP�3 `Distraction Vales 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6• iI 6 �I COM VEH 0 Ea 3 n
I- FIRST CONTACT 3 7__---_;__5 *II Yes.See Sidebar U1 0
Z ELGIN IL 60120 0 1 0 DZ49179 IL 2025 iismi
TELEPHONE
IL D 0 1 C4RJKAG5P8842257 StateFarm ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Zuniga. Hugo 3393440SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑Nuv 0 KKv ❑DV
/1 9 y 8 5 Other Other 2009 00-NONE 11_"j Q�,-_1 DUE TO CRASH ❑ 2 x
...
13-UNDER CARRIAGE 10( I FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:,�4 COM VEH 0 ® U1 W
FIRST CONTACT 12 7 , .5 •If Yes.See Sidebar
Z Carol Stream IL 60188 0 1 0 DM45806 IL 2025 REAR
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M
IL D 0 JS2YB413895101144 Allstate ❑Y J N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 811561497 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(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 El 11 4 04,24 /2025 08 58 ®pm in a Work Zone? NJ o1RP co
1 tT PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
F.; 2 0 2 99 + / 0 PM. ❑Construction *
1
R 3 0 ZSI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o 1 ® 11 4 ARREST NAME Zuniga. Emely.G. 11-901-A 1530000366 r ! El PM SLMT
ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
o N DI AM 30
r 2 0 ARREST NAME Zuniga. Emely.G. 3-707 1530000367 , r PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 302 06 ,03/2025 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- 'i---.r-_--; _
S?Liberty?St combination):or INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I - } (example:shuttle or charter bus):or C
< <----- -•-•; r+r ,+�+ 1 trans 3. Is d rtig emloyeesl5 or fewer in he course of he e mpl and yment employee a contract ner 73
9 1.1 = I • r } transporterpo -usually a van type vehicle or passenger car):(example:r w
L L.___a._ ' t. _t - 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
1+ I } } } for direct compensation(example:large van used for specific purpose):or
' L.._-a____. - I. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 'D
Bent?St Unit 1 , . . . placarding(example:placards will be displayed on the vehicle). D
-I
0
CARRIER NAME
� I� IADDRESS 0n
CITY/STATE/ZIP
I
Not To Scale I MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------4 - USDOT NO. ILCC NO. rn
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Owners Residence . 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