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HomeMy WebLinkAbout2025-00029632 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I011011000 I Ol 0 DID II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003813569' 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 AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY N OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00029632 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n ® ❑ RELATED ®Y ❑N 05 10 2025 ®AM ®YES 0 NO U1 N SPRING ST Elgin 09:37 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill FT/MI N E S W KIMBALL BALL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 uuv 0 ucv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 C) FOR DAMAGED AREA(S) FRONT TOWED U1 Q NAME(LAST,FIRST,M) mo /1 9 7 9 Honda Odyssey 2007 00-NONE © OUE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE ❑ IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0U2 00 <<T1 F 2 8 n 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH O 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2 • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i�6 C. VEH ❑ 133 1 O ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7 ; __5 *II Yes.See Sidebar Ut Z H363024 IL 2025 REAR TELEPHONE IL D 5FNRL38647B454563 Country Financial ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Ramirez. Marco.A. P010197336 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 ICv ❑DV Yr/1 9 9 4 Lexus RX350 2016 00-NONE ,�_"i Qr O DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ N U2 C Po M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5-II 6 [.;(.9 COM VEH ❑ N U1 CO F,,, FIRST CONTACT 1 Y� —_,SOS •IfYes.See Sidebar ELGIN IL 60120 B 1 0 CG95353 IL 2025 I 0 C M IL D JTHSE5BC2G5007090 State Farm ❑Y 123 N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 1972920-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI ,(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 02 / D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 N 11 1 05/10 /2025 09 37 ®❑pM 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 0 25 28 / / ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 -a, ARREST NAME Centeno-Sanchez. Patricia 11-601-Ax 1508000737 / / ID PM SLMT U 1 ® 11 1 •N CITATIONS •ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM El Utility o N t 2 El ARREST NAME Centeno-Sanchez. Patricia 11-305-B 1508000736 05 r 10 /2025 10 30 [M PM El 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 1508-Salgiado. Leandro 102 06 / 17/2025 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 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 truckrtrailer -< ` ` --I -' r INDICATE NORTH combination):or -I Mepryx, BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } } l 0 - r r r (example:shuttle or charter bus):or I 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O < I- -- i l Not fb Scale _I 1. } transporting employee �In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or CO L L.___a__._� I 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C } } for direct compensation(example::large van used for speific purpoe):o L L-_--a..... %` - t i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires driv er. O .D placarding(example:placards will be displayed on the vehicle). m ;0 CARRIER NAME Z i. ADDRESS 0I � i CITY/STATE/ZIP n _ MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other I "Y""1 USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 T. 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 to 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 Maroon Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/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 Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE