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HomeMy WebLinkAbout2025-00027237 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110000 1101 M1111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *X003605960* u, 1 U21 1 1 1 u, 2 U2 1 u, 1 1_12 1 u, 1 U2 99 1 10 u, 3 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 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00027237 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n WELD RD Elgin ® ❑ RELATED ®Y 0 N 04 30 2025 ®AM ❑YES ElPRIVATE NO U1 mo /day/yr 11.16 ❑PM FLOW CONDITION m ®15 /MI N E S © Weldwood Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 co Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 rary 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRONT TOWED U1 0NAME(LAST,FIRST,M) Carvajal Emergio.Medina. Emer io.J. mo 1 9 9 9 Chevrolet Express 2016 00-NONE , 2 0 DUE TOCRASH ® ❑ 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 5 ❑Y ®SNE❑ n 15-OTHER UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 �i COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1 Z 2255478B IL 2025 REAR TELEPHONE IL D 1 GAWG FFFBG 1259496 Travelers Indemnity ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire GW Nitzsche. Inc. 810-1T323881-22-43-G 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 73 m x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv 1 9 5 2 Hyundai Tucson 2008 00-NONE 0. Q1-_, DUE TO CRASH 0 p 2 73 0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraclion Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 11:, 4 COM VEH D ® U1 CO FIRST CONTACT 11 7�� _, _5 •If Yes.See Sidebar i ELGIN IL 60124 B 1 0 A625059 IL 2025 I 9 N IL KM8JN72D08U846773 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same 1333596-sfp-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman RESPONDER ui = (UNIT) (SEAT) (008) (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 1 04(30 (2025 11 17 ®❑pM in a Work Zone? NJ DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) O T 2 ❑ 2 99 ( ( 0 PM• ❑Construction * R 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 oER 11 1 ARREST NAME Carvajal Medina. Emergio.J. 11-902 327003148w ( ! ❑PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility r 2 ❑ ARREST NAMEAM x- T ( / ❑❑PM 0 Unknown work zone type 35 U1 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 35 327 Hromadka.Scott 801 368-Davenport , ❑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 4 N= 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` --I -' r INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } .=:\ (example:shuttle or charter bus):or X . 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 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 rt between 9 and 15passengers,includingthedriver, C } } for direct compensation(example:large van used for speific purose):or 0 L L.__-a..... - i. i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m I placarding(example:placards will be displayed on the vehicle). ;p 1 .1 D t CARRIER NAME —I `I ADDRESS 'n I n CITY/STATE/ZIP I - MOTOR CARR.ID ❑ Interstate ❑ Intrastate 1 I r 1 ❑ Not in Comm./GaA. Not in Comm.lOther O Y-__-. Not To Scale 1 ; ° ° 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. Xl Xl 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 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 ❑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 Green Maroon 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