HomeMy WebLinkAbout2025-00029354 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011000
l1111111101000
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003&14130
u, 1 U2 2 4 1 U, 4 U2 U, 1 u2 u, 2 u2 4 6 U1 1 U2 *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 ❑5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
yR 2025I 2025-00029354 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 -n
RT20 RELATED ®Y 0 N 05 09 2025 02:00 ®AM ❑YES ®NO U1
Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W LAMBERT LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EouES 0 Nuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0
FOR DAMAGEDAREA(S) FRObrr TOWED U1 Q
NAME(LAST,FIRST,M) q mo
1 9 6 7 Volvo VNL 2004 00-NONE „ •
Q , DUE TOCRASH ® ❑ E
13-UNDER CARRIAGE 10 i 2 FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 t6•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 I,.4 COM VEH ® 0 2 0
F. FIRST CONTACT 12 7 ;—, _5 *Irves.See Sidebar U1
Z Chicago IL 60630 0 1 0 P1028900 IL 2025 REAR
TELEPHONE
IL A 7 4V4NC9TJ04N357181 StassenInsurance ❑Y ®N U2 n-i
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 Same GRT14619B 1 rn
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER AJ
Refused ❑Y ❑ N 20 rg- 0
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr 12 _ C1
Ti 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1._5 CIOMs gee SidebarH
❑ C
CO
F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YONDER❑N U1 =
(UNIT) (SEAT) (00B) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
Pj
/
0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 4 Illinois.State.o. traffic light and grass. 05,09 ,2025 02 00 ®❑pM 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
v t 2 ❑ 150 DEXTER CT ELGIN IL 60120 28 06 05,09 ,2025 02 15 ❑PM ❑Construction
R O ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ®AM ❑Maintenance U2
—a, ARREST NAME Sinchi Yuquilima. Marcos. M. 11-601-Ax W1534000236 05,09,2025 02 40 ❑PM SLMT
o U 1 ❑ CITATIONS ISSUED PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
_ AM U, 45
r 2 ❑ ARREST NAME 05,09 ,2025 04 30 [M PM ❑Unknown work zone type
cf T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
2 3 0 - ❑AM Workers present? ❑
1534-Santiago.Jorge 401 , , ❑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 -' r INDICATE NORTH combination):or —I
i_ .:.. -:. i I I I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ (example:shuttle or charter bus):or
armI r r r X
I- A I I y I i- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } transporting employees In the course of their employment(example:employee
y^ .f transporter-usually a van type vehicle or passenger car):or COi. i. ..}----l. :.iifi� - } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
yw' for direct compensation(example:large van used for specific purpose):or O
i i ._ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
` i rXI
#. placarding(example:placards will be displayed on the vehicle).
I ~ I V —I
CARRIER NAME Stncht Loqictics Transportation z
0 ADDRESS 4610 N KEYSTONE AVE 1
D
w
CITY/STATE/ZIP Chicago 1 IL 160630 o
Not To Scale j 5
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I 0 Not in Comm./Govt. 0 Not in Comm./Other
�---------1 - USDOT NO. 2554023 ILCC NO. m
Xl
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 ® 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?
❑ Yes II No ElUnknown A
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 ®No 2
TRAILER VIN 1 1 UYVS25309P594304 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ® ❑ 0 Z
TRAILER 2 0 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 52 ft. 2 ft. Z
Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY1T0:
DUE TO VEHICLE CONFIG. 6 CARGO BODY TYPE LOAD TYPE