HomeMy WebLinkAbout2025-00031437 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets _ 01111101111
011011000 fllfl
I III 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003632647-
u, 1 U21 3 4 1 U, 8 U2 1 U, 1 U2 1 U, 1 U2 1 5 12 U1 13 U213 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00031437 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
DUNDEE AVE Elgin
® ❑ RELATED ❑Y ®N 05 18 2025 ®AM ❑YES IX]NO U1 -<
PRIVATE mo /day/yr 00:03 ❑PM FLOW CONDITION ITI
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 U)
I 0 ®/MI N E p W Summit Ave WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ElN PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUES 0 rary 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0Cardozo Alvarado.Gustavo 0 2 /
yr 13-UNDER CARRIAGE IE
10l ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 4 rn
M 2 4 ❑Y ❑SYTHER
SE El UNK VEH. 9 AT CRASH M IN ENGAGED9 99-UNKNOWN 9 76-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 j$J 1 0
~ ELGIN IL 60123 0 1 FIRST CONTACT 4 7 ; __5 *IIYes.SeeSidebar U1
Z 3380482B IL 2026 Isui
TELEPHONE
IL D 0 1 FT8W3B68FEA70099 State Farm ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR .-
Same 1693287-sfp-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 73
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
/1 9 9 3 Honda Civic 2009 00-NONE ,�_O' 12"M"_, DUE TO CRASH ❑ C 2
0y Yr ®13-UNDER CARRIAGE ( 2 FIRE ID El U2 C
c
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X
❑Y ❑N IN UNK VEH. AT CRASH 99-UNKNOWN *Oistraclion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:�4 COM VEH ❑ ® U1 co
FIRST CONTACT 1 O 7-• '_.5 •If Yes.See Sidebar
H ELGIN IL 60120 0 1 CK74462 IL 2026 I O N
M
IL D 0 2HGFA55569H702245 American Freeedom ❑Y ®N RDEF 71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 12-2403583-01 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 995 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 07 /
LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
N 1 ® 11 1 05/18 /2025 00 03 ®❑PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1
o"
2 ❑ 20 08 / / ❑PM ❑Construction >E
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME Cardozo Alvarado.Gustavo 3-707 752867 / / El PM SLMT
o u ® 11 1 llg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
AM 30
r 2 ❑ ARREST NAME Cardozo Alvarado.Gustavo 11-402-A 751866 / / 0 PM 0 Unknown work zone type U1
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1539-Vargas. Miguel 102 - / / ❑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 -' / f INDICATE NORTH combination):or .Z-1
/ / BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} }
// / r r (example:shuttle or charter bus):or
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier i O
< }.___A.._.� / / axm; } } 1. transporting employees in the course of their employment(example:employee
/ / transporter-usually a van type vehicle or passenger car):or CO
L }-----}----I. / / - I. } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. w
/b; for direct compensation(example:large van used for specific purpose):or
. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
g— placarding(example:placards will be displayed on the vehicle). XI
I CARRIER NAME
/ -�'� — — - ADDRESS0
/ / VD/)
/ / C)
[seem CITY/STATE/ZIP g
r / - i. MOTOR CARR.ID 0 Interstate El Intrastate 5
4.
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;____Y_._-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 VIM 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 White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
_Artier/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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE