HomeMy WebLinkAbout2025-00034957 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I011011000I a2IIIII III I 1111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00383 '
u, 2 u210 1 1 1 U1 8 U2 1 U199 u2 1 U, 1 U2 1 4 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00034957 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m1225 FAIRWOOD CT Elgin10:12
® ❑ RELATED ❑Y ®N 06 01 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg)DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 eaves 0 NW 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Escalante Perez. Ma polio. E. 1 0 /
yr 12
13-UNDER CARRIAGE FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 23 U2 2 M
M 9 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 I, 4 COM VEH 0 Ea 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
Z ES74197 IL 2026 REAR
TELEPHONE
IL D 3C4NJCBB8JT488749 NA El ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same NA 1 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr 10;f 12 ( 2 FIRE ❑ ® U2 2 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 ❑ ® SPDR n
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN I `0i$tractlon Value 9 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ' - it COM VEH D ® Ut CO
F,,, FIRST CONTACT 7 Q 6 l'�.5 *If Yes.See Sidebar
BB47313 IL 2026 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1 G 11 C5SA9DF348163 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Benitez-Rueda,Camilo,A. 3499558 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
m
/ / S#OCC D
71
/
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 06,01 /2025 10 17 ®❑PM in a Work Zone? ®N DIRP co
I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 20 99 , , ❑PM ❑Construction >E
R 1 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Escalante Perez. Magnolia E. 11-601 1549000103 , ! ❑PM SLMT
U 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM® 25
• ElUtility
r 2 ❑ ARREST NAME Escalante Perez. Magnolia E. 3-707 1549000104 06 i 01 ,2025 04 13 ❑PM ElUnknown work zone type U1co
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1549-Brown, Bryan 501 07 , 14,2025 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.
r ----r••--, , A - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- i•____r____; I _ 01. Has r g ore than pound { a p .truck or trucktrarler 1. Hasaweight ratio m 10000 5 ex m le -<
INDICATE NORTH combination):o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driverC
_ } (example:shuttle or charter bus):or
_-.a--_-. cv l... _ I, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I- `-
g air - } } } transporting employees in the course of their employment(example:employee X
"C = l I transporter-usually a van type vehicle or passenger car):or w
i. .. -,. � Not I ( } } } 4. Is used or designated to transport between 9 and 15 passen rs,including the driver, y
(� Q Scale I for direct compensation(example:large van used for specific purpose):or
L L--_-a-....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). III
;p
1 `fr1 I>
IF f I__ 1 CARRIER NAME Z
ADDRESS 0
I CITY/STATE/ZIP
U)n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. Not in Comm./Other
�I. -------- - USDOT NO. ILCC NO. rn
XI
Source of above Z
. —I
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Tan
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Pepes Towing/Mike More Miles . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE