HomeMy WebLinkAbout2025-00025644 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
101101100 III 110011010101111
11 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003798942
u, 1 U21 3 4 1 U1 3 U2 1 U, 1 1_12 1 U, 1 U2 1 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 2
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2025I 2025-00025644 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
SUMMIT ST Elgin02:56
® ❑ RELATED ®Y 0 N 04 23 2025 ❑AM ❑YES ®No U+ -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT l MI N E S W WAVERLY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Cook HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
1 1 /
yr ++- +2 -
13-UNDERCARRIAGE +al • 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 04 r<rl
F 2 SYTM 4 ❑Y ®$NE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN 9 76•TOP 3 ,Distraction Value I ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a i S ii,4 COM VEH ❑ El 1 0
" �- ELGIN I L 60123 A 4 0 FIRST CONTACT 6 r �Q-_s C.
If Yes.See Sidebar U1
ZER83466 IL 2025
TELEPHONE
IL D 0 1 G KKN LLS6KZ279109 Kemper Insurance ❑Y I l N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Viveros Sanchez.Gabriel 12A0001545771 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
$ /1 9 yf 1 Nissan Pathfinder 2016 00-NONE i1_j Qr-_, DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 10( I. 2 FIRE 0 ® U2 C
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *OistraclIon Value 1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
H ELGIN IL 60120 B 1 0 Q331496 IL 2025 I 0
M
IL 0 5N1AR2MMXGC645388 Allstate Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 911164658 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOOi (SEX) {SAFT) (AIR) (WI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL)
2 3 07 /
:A
/ / UI 1 D
/ / 2 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 4/ ,3/ /025 03 00 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
2 0 25 28 41 /31 /025 03 11 ®PM ❑Construction *
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Viveros Hernandez. Erika 11-306 1511000354 41 /3/ /025 03 15 Igi pM SLMT
1 ® 11 1 0 CITATIONS ISSUED 0 PENDING Utility
o uSECTION CITATION NO. ROAD CLEARANCE TIME AM• • ❑
r 2 El ARREST NAME Viveros Hernandez. Erika 6-101-A 1511000353 41 /31 /025 04 00 0 PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1511-Ayala. Roberto 200 51 , 71 /025 01 30 0 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•"--, , - ; 0A 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- }----------1 aummnilt J 1
I ~ } INDICATE NORTH combination):or .Z�1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
— — — I— — — 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
}_--------•i `
- } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
C
i. }-----}----; - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
0
for direct compensation(example:large van used for specific purpose):or
L L____a____. . _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
— — —
Il 101111 placarding(example:placards will be displayed on the vehicle). X/
—1
EACARRIER NAME Z
E 0
ADDRESS T.
® '' I rn
CITY/STATE/ZIP
o
Not To Scale I MOTOR CARR.ID 0 Interstate ❑ Intrastate -
1 I rI
1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
i. -Y- "• - USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
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 ❑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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White White
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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE