HomeMy WebLinkAbout2025-00034994 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0038.40612
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00034994 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
N JACKSON ST El In01:56
® ❑ RELATED ' ' 0 N 06 01 2025 12,— ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FTlMI N E S W LAWRENCE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROf'tf TOWED U1 Q
NAME(LAST,FIRST,M) I- mo
!2 0 0 2 Dodge Ram ProMaster 2023 00-NONE ,, • 12 , DUE TO CRASH ❑ VI
13-UNDER CARRIAGE 16 O 2 FIRE 0IE
2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP® *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 �i,4 COM VEH 0 j$J 1 0
~ Naperville IL 60540 0 1 0 FIRST CONTACT 1 7_; -_5 *Ifves.SeeSidebar U1
Z P FP231222 IL 2025 REAR
TELEPHONE
IL D 0 3C6LRVDG1 PE583940 Fisher Brown Insurance ❑v ®N U2 Si , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Tank Logistics LLC RAC9438595 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
98 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
!2 0 0 1 Hyundai Elantra 2014 00-NONE O Qi-O DUE TO CRASH 0 2
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7� .5 C.
IfYes.See Sidebar
H ELGIN IL 60120 0 1 0 ET78008 IL 2025 I 0
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IL D 0 5NPDH4AE9EH468637 United Equitable ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same IL0000889 BAG $
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)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 06(O1 l2025 01 56 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 C)
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0
2 0 2 99 ( ( ❑PM• ❑Construction *
Z 3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
11-901-A W1528-000279 / ! ❑PM
aARREST NAME PlerCe• EPIC.�. SLMT
® 11 1 igiCITATIONS ISSUED 0 PENDING Utility
o N 1 SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑
t 2 ❑ ARREST NAME Vazquez Vazquez. Ronald. F. 3-707 1528-000278 06(01 l2025 02 00 ®PM ❑Unknown work zone type u1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
1528-Rivera. Kevin 601 06 (23(2025 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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
w` 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }-----I-----1 N - } INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
111.jr y 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
}. -A- --i `
,• } } } transporting employee in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):orCO
L .g . C
I- I- --I-----I - } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
•for direct compensation(example:large van used for specific purpose):or
__ _ L i } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
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p� , , , , , CARRIER NAME Z
- ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
IVOf TO SCels I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
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i. --- '-1 - USDOT NO. ILCC NO. m
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Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No Z
Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
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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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . 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