HomeMy WebLinkAbout2025-00031124 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100001
IIII 1111111
I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003823689
u, 1 U21 1 1 1 U110 U2 1 U, 1 1_12 1 U, 1 U2 1 1 12 u1 2 u2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00031124 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S STATE ST El In02:59
® ❑ RELATED ❑Y ®N 05 16 2025 ❑AM ❑YES ®NO U1
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
0 !MI N E S VY West Chicago St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
® 0 g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Reynada. Brandon. M. 0 6 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 El ®SNE❑UNK VEH. 0 ATCRASHIND 0 99-UNKNOWN 016•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D i all} 4 COM VEH 0 Ea 1 C)
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 7 O7 _:,- -_5 *II Yes.See Sidebar U1 0
Z FG52746 IL 2025 REAR
TELEPHONE
IL Other 0 4A3AB36F07E077229 First Chicago ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILS1137015-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
x DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0
!2 0 0 2 Chevrolet Express 2009 00-NONE 11_"�, t2..-_1 DUE TO CRASH ❑ ® 14 �7
o Yr 13-UNDER CARRIAGE 10) t 2 FIRE ID El U2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9;1,6-TOPO3 * 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 8-.l. 6 j( 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 Y'_, _5 •• •IT Yes.See Sidebar
n ELGIN IL 60120 0 1 0 2434777B IL 2025 aR 0
Z
IL D 0 1GCHG35C791102485 StateFarm ❑y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Colin. Francisco 3581532SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 ® 11 1 51 ,61 ,025 02 59 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 04 99 1 1 0 PM ❑Construction *
1
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o 1 ® 11 1 ARREST NAME Reynada. Brandon. M. 11-601-Ax W1528-000262 / ! El PM SLMT
El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
S' N 0
AM• ❑Utility
30
T 2 0 ARREST NAME Moran. Kobe 6-101 W1528-000261 5) 171 1025 03 00 0 PM ElUnknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
1528 Rivera. Kevin 601 , ❑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
I1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
i- }____r__--; I INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r (example:shuttle or charter bus):or 0
Mabpeae, j
I I , : : , T,
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} -A- --i I.- } I.- transporting employees In the course of their employment(example:employee
_ _ _ _ } transporter-usually a van type vehicle or passenger car):or
L L.___a__ 4. Is used ordesi natedtotrans transport passengers,including y} } } g po passen rs,includi the driver,
." r I I for direct compensation(example:large van used for specific purpose):or
_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
m
Not To Scale I I 1
CARRIER NAME Z
I Li - __ ADDRESS D
11 1 rn
n
CITY/STATE/ZIP g
tmneuoner 1'''r - i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. --- --• - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑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
Red White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE