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HomeMy WebLinkAbout2025-00034308 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 I0fl 111111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03839508 u, 1 U21 3 4 1 U, 2 U2 1 U, 1 u2 1 U1 1 u2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑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-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00034308 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 05 29 2025 ❑AM ❑YES ®NO U1 -< N MCLEAN BLVD Elgin mo /day/yr 05:08 ®PM FLOW CONDITION Ill • gr1090!MI N E O W Abbott Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 7 / yr 13-UNDER CARRIAGE ©,I ©:. 2 FIRE 0 NI E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 (Tl M 2 4 SY❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s IL 6 I,.4 COM VEH 0 j$J 1 O ~ Palatine IL BOOB? 0 1 0 FIRST CONTACT 12 7_; _-5 *II Yes.See Sidebar U1 Z EF51062 IL 2025 TELEPHONE IL D 2D4RN5DGOBR682578 Erie El ®N U2 M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Infinity Pro Q082431187 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 73 rg. x DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV /1 9 8 4 y Chevrolet Traverse 2015 00-NONE ,1_"i t2"-_, DUE TO CRASH El (� 2 73 0 13-UNDER CARRIAGE 10 1 z FIRE ® C) ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 3 POINT OF s 1I 4 COM VEH D ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - MI' FIRST CONTACT 6 Y :j_ ._5 •If Yes.See Sidebar — Elgin IL 60123 0 1 0 EU56777 IL 2025 i 0 Si)c IL D 1 G N KRJ KD1 FJ202201 Direct Auto ®Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Jaurez Estrada. Mayra.G. PAIL001230848 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP U1 = (UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 11 / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur IDY U2 Z N 1 ® 11 1 5/ /9/ /025 05 08 ®AM in a Work Zone? ®N DIRP co 1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,, en 2 0 28 99 51 r 91 /025 05 08 RI 0 Construction F R 3 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Chebyshev. Nikita 11-601-Ax 1531000059 5/ /9/ /025 05 13 Igi pM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility T 2 El ARREST NAME 51 /9/ /025 05 37 ®PM 0 Unknown work zone type U1 0 AM 35 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 35 1531-SchEmbach.Jack 502 71 112 /25 01 30 ®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 1 ADDITIONAL UNITS FORMS. r ----r••--, , y1 ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z N U } INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer combination):or -< i- i-- _r__--; I 1 _ 1 Abbott/Dr BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n i_ - } (example:shuttle or charter bus):or 0 - ------..----; transporti3. Is ng employened to es inthe course passengers5 or fewer thir emplod yment example:employeener I } F L -----}----; - • } } } transporter sed or des gnated to transport between 9 and 15rpassengers,including the driver. N j Mdeon�Nd Not To Scale 1 for direct compensation(example:large van used for specific purpose):or O } I. I .. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). ,Zmt CARRIER NAME Z =jI.� O t'_.r.'I;� _ __ T. ADDRESS o (;'`i,A CITY/STATE/ZIP g m - MOTOR CARR.ID 0 Interstate ❑ Intrastate r I 0 Not in Comm./Govt. Not in Comm./Other ----------- [ L .. i. ..... ..... USDOT NO. ILCC NO. rTt XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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 71 IDOT PERMIT NO. WIDELOAD'; 0 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 1-1 TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Other/Owners shop . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE