HomeMy WebLinkAbout2025-00032455 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03831404
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 CZ OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00032455 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ' V 0 N 05 22 2025 E�IAM ❑YES ®NO U1
LAWRENCE AVE Elgin06:40
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N CRYSTAL AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) I330bfr TOWED U1 Q
Kindle. 0 1 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 SY15-OTHER
8 ❑Y ®SNE M ElUNK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN 016-TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� 6 �'.4 COM VEH 0 j$J 1 n
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 9 O_: -.-5 •II Yes.See Sidebar U1 0
Z 908AA675 IL 2025 E
TELEPHONE
IL D 1 G 1 PE5SB8D7187313 Hugo ❑Y ®N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Same 1389883 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑Nuv 0 NOV ❑DV
!1 9 9 5 FR
^ NAME(LAST,FIRST,M) Ortiz Gabriel. Brenda.A. yr Dodge Durango 2015 00-NONE 11_"j Q�,-_, DUE TO CRASH p 2 x
0 lij 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 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 6-it 6 1:, COM VEH ❑ ® U1 W
FIRST CONTACT 12 7�_, .5 •(ryes.See Sidebar
F... ELGIN RFJ
IL D 1 C4RDJAG2FC180747 State Farm ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 0978082SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 4 51 )21 l025 06 46 ®❑PM in a Work Zone? ®N DIRP >co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 i C)
o� T
2 ❑ 23 2 ) / ❑PM ❑Construction X
3
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Kindle.Cory 11-1204-B W340000137 ! ! El PM SLMT
o Nu ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
ARREST NAMEAM
T1 2 ❑ / / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
340-Phillips. Kathryn 600 , ! ❑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
i- }-----l-----' M - INDICATE NORTH combination):orrating thanpound (example:truck or truck/trailer
1. Has aweightmore10,000 5
•
tion):
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Net TO StaP9�, _ } (example:shuttle or charter bus):or C)
i_ i., -:. l '
3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O
- y I. } } transport) em to ees In the course of their employment
•
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ng p y ployment(example:employee
�� transporter-usually a van type vehicle or passenger car):or co
-- -- - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
mi for direct compensation(example:large van used for specific purpose):or i O
No
L L__ _a..... in - t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
l l _ i r "NI • placarding(example:placards will be displayed on the vehicle). XI
a
— 1.1r • D
49 - - _- CARRIER NAME Z
N. ADDRESS 'n
- V)
• C)
- CITY/STATE/ZIP g
- MOTOR CARR.ID 0 Interstate 0 Intrastate
l I r l ❑ Not in Comm./Gout. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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
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
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE