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HomeMy WebLinkAbout2025-00026253 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 101101100 VI VIII ft 11011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003797693 u, 2 U2 1 1 1 U, 6 U2 1 u, 1 1_12 U, 1 U2 1 4 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00026253 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn 1164 W CHICAGO ST El In02:12 ® ❑ RELATED ❑Y ®N 04 26 2025 ®AM ❑YES ®NO U1 -< g PRIVATE mo /day/yr ❑PM FLOW CONDITION m _ COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEON. 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 3 ! yr 13-UNDER CARRIAGE ©i O.._2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m M 2 SY5 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a ii.4 COM VEH 0 j$J 1 0 F. ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z DM34083 IL 2025 REAR TELEPHONE IL D J N KCV61 F69M361953 Progressive ❑v Il N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 990778680 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 0 p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0 NUV 0 NGv 0 DV CIRCLE NUMBER(S) U1 yr 13-UNDER CARRIAGE 10 ©),, E FIRE ID El U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 El SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16 ❑ -TOP 3 9 9 X a Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value POINT OF 8 '4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -j�'`_ COM VEH ❑ ® CO FIRST CONTACT 11 7 _,__5 ••If Yes.See Sidebar H AL23293 I L 2025 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FAH P24W08G 175687 StateFarm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Maxwell.Joseph.A. G832801D1513 SAC E 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) U2 996 r m ' ##occs y 71 / 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 04/26 l2025 02 12 ®❑AM 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 o" 2 ❑ 08 28 1 , ❑PM ❑Construction * Z 3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Villagomez.Giovanny 11-601-Ax 752886 / ! ❑PM SLMT l$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility t 2 ❑ ARREST NAME Villagomez.Giovanny 11-701-A 752885 04)26 ,2025 02 30 MPM ❑Unknown work zone type U1 35 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1513-Mann. Nathaniel 601 331-Ziegler 05 , 19,2025 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 0 ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z NRMelrow4Ave 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` --I -n r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or X L A 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 L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C I 1 } } } for direct compensation(example:large van used for speific purose):or N I O w.?chlcepo?8t I. < < < t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ��pp placarding(example:placards will be displayed on the vehicle). XI— — — — — —Unit7';;� , I> I . ■ ,s4t, CARRIER NAME Z Gdras Y ADDRESS 0 C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other I I I I ' USDOT NO. ILCC NO. m s.9Melroee7Ave. Not To Scale f , , , , , XI Source of above z . 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 Z TRAILER 2 ❑ 0 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. 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