HomeMy WebLinkAbout2025-00019811 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets _ 01111101111 01101100 0110 1011110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 2025I 2025-00019811 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ❑Y ®N 03 29 2025 ®AM ❑YES ®NO U1 -<
RAYMOND ST Elgin11:43
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv (8)icy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 TOWED
0
0 9 /
yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION IN ENGAGED
LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 2 M531 M 9 4 ❑Y CI DUNK VEH. 9 AT CRASH 9 015
OTHER UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN =
T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i L 6 4 COM VEH 0 0 5
c Z ELGIN IL 60120 0 1 0 EV21029 IL FIRST CONTACT 99 7_;REAR
__5 *If Yes.See Sidebar U1
0
TELEPHONE
IL WBAVA33537KX70328 Kemper Insurance ❑Y ®N U2 r
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12AU001574825 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES ❑row 0 NOV ❑DV
!1 9 r 1 Ford Explorer 2007 00-NONE „ " 12' _1 DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE FIRE 0 El U2
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I ',.4 COM VEH 0 ® U1 co
FIRST CONTACT 8 7�_, _5 ••Iryes.See Sidebar C
ELGIN IL 60123 0 1 EA17149 IL I 0 fp
Z
IL 1 FMEU74E37UA58630 Direct Auto ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Carballido.Oneisy PAI L001112674 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 9 1 City of Elgin Utility Pole 03,29 /2025 11 43 ®❑AM in a Work Zone? ®N DIRP co
1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U, C)
v 2 ❑ 150 DEXTER CT ELGIN IL 60120 04 26 / / 0 PM ❑Construction >E
1
Z 3 ❑ El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Yanez.Gary 11-707-B 410000708 / / El PM
o u 1 ® 1 3 CITATIONS ISSUED 0 PENDING TIME • El Utility
SLMT
o N SECTION CITATION NO. ROAD CLEARANCE 0 AM 30
Ti 2 0 9 3 ARREST NAME Yanez.Gary 11-402-A 410000719 , r PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
410-DeLeon.Jessica 401 275-Engelke 04 , 15,2025 01 30 ®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 unitshave been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
1 ADDITIONAL UNITS FORMS.
. 0
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 truckrtrailer -
i- ;--_.i-----4 INDICATE NORTH combination):or
far I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or
X
- ----- -•-•; I transporting employeened to sl5 or fewer in the course passengers
rhea emand ployment operated
xample:employee
transporter X
I. I- I-
transporter-usually a van type vehicle or passenger car):or CD
L }-----}----; C
nip
- } 1. 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
t rr r_ for direct compensation(example:large van used fors specific purose):or
S . J I
t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
XI
—
mow. CARRIER NAME Z
0y , (s` r ADDRESS
D
CITY/STATE/ZIP 0
0
MOTOR CARR.ID ❑ ta ❑ -0‹I I ❑ NotInters in Cotemm./GaA. Not inIntrastate Comm./Other
;____Y____ USDOT NO. ILCC NO.7 rn
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Source of above z
. IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No =
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other t Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE