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HomeMy WebLinkAbout2025-00028513 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110000 111 00 000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003809.53 u, 1 U21 1 1 1 u, 2 U2 1 u, 1 u2 1 u,99 U2 99 1 12 u, 13 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00028513 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m195 RT20 El 04:05 ® ❑ RELATED ❑Y ®N 05 05 2025 ❑AM ❑YES ®NO U1 -< _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ❑ FT/MI N E S W Cook HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q NAME(LAST,FIRST,M) mo /20 0 5 Toyota Matrix 2008 00-NONE , 12 , OUETOCRASH ❑ EN E 13-UNDER CARRIAGE ©10,I !�. 2 FIRE 0IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn F 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN ENGAGE0 99-UUNKNOWN THER 9 16-TOP 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 1i 4 COM VEH 0 0 2 C) H 1 ELGIN I L 60120 0 1 CB99654 IL FIRST CONTACT 11 7_; __s Yes.See Sidebar U1 REAR Z E TELEPHONE IL D 2T1KR32E28C694894 State Farm ❑Y ®N U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 GONZALEZ CRUZ.GUILLERMIN 0202405 SFP 13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 lily 0 Ncv 0 DV 0 0 0 FROM TOWED Jetta 2019 00-NONE i1"j t2..-_, DUE TO CRASH ❑ 2 x 0 Yr 13-UNDER CARRIAGE 10'I 2 FIRE ❑ ® U2 C c ig F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,1,6-TOPO3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN O Oistraglon Value 9 Ut 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-iI 6 i_.,_4 COM VEH ❑ ® CO FIRST CONTACT 4 7 ,__5 •If Yes.See Sidebar ~ 60110 0 1 BX51198 IL 2025 I 9 CC/) M IL D 0 3VWC57BU8KM273126 State Farm ❑Y ®N RDEF .73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Wasylko.Janet 1978118-SFP-13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused 0 Y°ND 0 N u1 = (UNIT) (SEAT) (DOB) (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 ❑Y U2 Z u 1 El 11 1 05/05 /2025 06 15 ®pm AM in a Work Zone? NJ 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 18 18 N 3 0 0 CITATIONS ISSUED 0 PENDING + / 0 PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3 -a ARREST NAME / / 0 PM ' o, N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility SLMT r 2 ❑ 45 AM T ❑PM 0 Unknown work zone type U1 cf- ARREST NAME 1 / ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 547 Homeier.William / / ❑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 INDICATE NORTH comb nation)or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC L _ } (example:shuttle or charter bus):or Rrzo 'a 13 3. Is designed to carry15 or fewer N_ g passengersttheir and operated a contract career O } I• I. transporting employees In the course of thir employment(example:employee -- transporter-usually a van type vehicle or passenger car):or w C L L.___a__._J. 4. Is used ordesi nated to trans rt between 9 and 15passengers,includingthedriver, _ Not To Scale I } } } for direct compensation(example:large van used for speific purose):or 0 El D L L____a iany____� t 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires, placarding(example:placards will be displayed on the vehicle). ,Zmt CARRIER NAME Z I - ADDRESS 0T.9r�..9Plnq rA / CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other I----- ----4. - USDOT NO. ILCC NO. m XI Source of above z . MCS 0 Yes 0 No 0 Unknown Out of Service 0 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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE