HomeMy WebLinkAbout2025-00031922 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
1011011000 01
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003626549'
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S $501-$1.500 ®ON SCENE
❑ 1
VEHICLE/PROPERTY 0 OVER 1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00031922 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 05 20 2025 ®AM ❑YES ®NO U1 -<
N EDISON AVE Elgin mo /day/yr 06:07 ❑PM FLOW CONDITION m
_
ONOO COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
!MI N E S W Larkin Ave WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ID PARKED El DRIVERLESS 0 PED CI PEDAL 0 EOUES 0 NOV 0 icy CI Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
FOR DAMAGEDAREA(S) •FROM�TOWED U1 0Gonzalez Cortes.Abel.J. 1 0 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M I 2 SYTM 5 ❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TDP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 1,,a COM VEH 0 Ea 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7_: __5 *lives.See Sidebar U1
Z EZ18838 IL 2025 REAR
TELEPHONE
IL D 0 1FMCUGHX9DUD22715 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12AU001553235 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 Dv
yr 10;j 12 c, 2 FIRE ❑ ® U2 2 C
o _ 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 0 ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction Value U1 0 -
POINT OF 8 I a
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR . 6 . COM VEH ❑ ® CO
F,,, FIRST CONTACT 5 O7 a=Q)OS •If Yes,See Sidebar C
EW56367 IL 2025 i:EAu 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
J N RARO5Y7WW023547 Unknown ❑Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Hernandez. Ramiro Unknown BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
RESPONDER
Y°®N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 6 08 / M 2 5 0 1 0
m
/ / #OCCS >
/ / UI 2 m
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ID 18 1 05,20 /2025 06 44 ®❑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
✓ 2 ❑ 20 99 05,20 ,2025 O6 08 ❑PM El Construction
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Gonzalez Cortes.Abel.J. 11-709-A 2025-000065 05/20/2025 06 14 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
AM 30
T 2 ElARREST NAME 05/20 /2025 07 00 M PM ElUnknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1547-Steele.Justin 601 07 ,01 ,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.
j t
r ----r••--, , S'� A CMV is defined as any motor vehicle used to transport passengers or property and: Z
4 , .. 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
i- }--_.r-_--; 1 w .,;, } combination):or -I
INDICATE NORTH p1
BY ARROW 2 Is used ordesi nedtotran transport` g sp passengers including the driver
r . ,. (example:shuttle or charter bus):or C
---- ---- �t � .�
Not To Scale �-
�� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
- } } } transporting employees In the course of their employment(example:employee X
L __I.,.. ...I. iiii�r ; - } } } } transporter sed or des gnated to transport betweelly a van type vehicle or n 9 andr 15rpassengers,including the driver, w
for direct compensation(example:large van used for specific purpose):or O
L t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
a placarding(example:placards will be displayed on the vehicle).
m
1 CARRIER NAME Z
ADDRESS 0
w
CITY/STATE/ZIP 0
0
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I I -I- I r1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I I '
USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown E
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
0 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
White Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE