Loading...
HomeMy WebLinkAbout2025-00034874 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I011011000 h0 1110111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003E38129` u1 1 U21 2 4 1 UI 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 15 U1 1 U2 1 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-S1,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00034874 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I RAYMOND ST Elgin11:17 ® 0 RELATED ®Y ❑N 05 31 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W DWIGHT ST COUN NTY PROPERTY ❑Y ® DOORING Ely #OF MOTOR 0 SLOW 15 to ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 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 0 0 T TOWED U1 O FOR DAMAGED AREA(S) FROM Var as. Bertha.A. 0 4 / yr 13-UNDER CARRIAGE ©, �:. FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m F 2 4 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 4 COM VEH 0 Ea 2 O F. FIRST CONTACT 12 7_:—_,__ _5 *IIYes.See Sidebar Ut Z SOUTH ELGIN IL 60177 0 1 0 DC97477 IL 2025 REAR TELEPHONE IL D 0 2FMDK53C99BA19913 Talro Insurance ®Y 0 N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire 99 9 Same QPS-600898 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 ou N DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 i sv 0 Ncv 0 Dv 00!2 0 0 6 Chevrolet Blazer 2004 00-NONE 1i_` t2 "_, DUE TO CRASH ❑ C 2 .. 13-UNDER CARRIAGE 1 2 FIRE ID ® C U2 c Yr F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i 6 l!- COM VEH D ® U1 CO FIRST CONTACT 9 7 _, _s •It Yes.See Sidebar C Z South Elgin IL 60177 0 1 0 EY99018 IL 2025 I 0 Si) n IL D 0 1 G N DT13X14K137134 None ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same None BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 03 / LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y N 1 ® 11 4 co 51 / 11 /025 11 17 ®PM AM in a Work Zone? ®N DIRP D 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 2 28 51 /11 /025 11 27 ®PM ElConstruction <w O 0 zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 3 ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Vargas. Bertha.A. 11-601 S1542-000280 51 /11 /025 11 33 Igi pM SLMT igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM El Utility N 30 t 2 0 ARREST NAME Vargas. Bertha.A. 3-707 S1542-000278 61 /12 /25 00 40 [M PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1542-Chase. Ethan 401 61 , 71 /025 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 ` -'- ' r INDICATE NORTH combination):or -I i_ .:.. -:. lij 1 el 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r (example:shuttle or charter bus):or C) r r X Not To Scale 1 3. Is desgned to carry 15 or fewer passengers and operated by a contract career I 0 - . . . transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a____� :. I. } 1} 4. Is used or designated to transport between 9 and 1passengers,includingthedriver. C 1 - for direct compensation(example:large van used fors specific purose):or to 0 < <--_-a-.... umr - 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 . 1 II CARRIER NAME Z ADDRESS 0 1 r i. i. i. i. 4. CITCITY/STATE/ZIPV) C) MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i- --- --1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 Black White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE