HomeMy WebLinkAbout2025-00030613 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011000 I
11101 1
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036179OS
u, 1 U21 2 4 1 U1 2 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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00030613 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
N LIBERTY ST Elgin02:59
® ❑ RELATED ®Y ❑N 05 14 2025 ❑AM ❑YES ®NO U1
g PRIVATE mo !day/yr ®PM FLOW CONDITION M_
FT!MI N E S W FRANKLIN N ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 3 Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 Mlles 0 NW 0 Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O 0
FROf'rf TOWED U1 Q
NAME(LAST,FIRST,M) Hernandez Ortiz.Santiago.A. mo yr Nissan Rogue2017 00-NONE
1t, 12
Q OUETOCRASH ® ❑ E
13-UNDER CARRIAGE 101 O 2 FIRE ❑ al
0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$j U2 171
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP® *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I,.4 COM VEH 0 0 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_; _-5 *II Yes.See Sidebar Ut
Z EU51424 IL 2025 REAR
TELEPHONE
IL D 0 JN8AT2MV8HW265341 Progressive ❑Y IlN U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 980854663 1 I—
ra HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ❑ N 2 c
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 icv 0 Dv
yr Dodge Caravan(inc Grand)2013'' oo-NONE O1 Qj.O DUETOCRASH rg D 2 x
o 13-UNDER CARRIAGE 10 I I.. 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i d.._ 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 _,r_5 C.If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 CZ17675 IL I Si)0
Z
IL D 0 2C4RDGBG4DR628850 Safeway Insurance ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
CORDOVA CORONA FCO. Miguel.A. 4188384-IL-PP-001 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 12 / M 2 4 0 1 0
m
/ / #OCCS >
/ / U1 1 D
/ / 2 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 05,14 /2025 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: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 23 15 , , ❑PM ❑Construction >E
R I 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME Hernandez Ortiz.Santiago.A. 11-1204-B 476000376 ! ! ❑PM SLMT
oN 1 ® 11 1 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
T 2 El ARREST NAME Hernandez Mendez.Yerisandra 6-303-A 476000377 05 r 14 /2025 04 05 ®PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos.Clarissa 202 391-Jacobucci 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 truck trailer -<
c ` --I- ' I. INDICATE NORTH combination):or -I
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
= $ 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
-- Ud!2 - } } } transporting employee In the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
-- -- I i I - 1 } } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
r I for direct compensation(example:large van used for specific purpose):or o
L i____a____1 / $ \�— _ t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
rr.:t t - -- . 1
ranorae< CARRIER NAME
FrwgY M l4d Z
—� I ADDRESS 0
r r T 1 i r
CITY/STATE/ZIP C)0
_Not 10 8CA/8i - i. i. i. 4. MOTOR CARR.ID 0 Interstate El Intrastate
5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
r -----Y----1 - USDOT NO. ILCC NO. m
XI
Source of above 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
Black Blue.Dark
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE