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HomeMy WebLinkAbout2025-00035753 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011000 flnnn10000000000 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003843028 u, 1 U21 1 1 1 U1 5 U2 1 U, 1 1_12 1 U1 1 U2 1 5 10 u1 6 u214 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00035753 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n BIG TIMBER RD EIIn ® ❑ RELATED ❑Y ®N 06 04 2025 ❑AM ❑YES ®No u1 -< 10:48 g PRIVATE mo /day/yr N PM FLOW CONDITION m FTlMI N E S W MORNINGSIDE DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y N N WITH VEHICLESOT, INVLD DO STOPPED U2 —I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FRONT TOWED U1 Q NAME(LAST,FIRST,M) ROLDAN PEREZ.JENNER. E. mo Toyota Camry 2011 00-NONE ©1 O'_, DUE TOCRASH ® ❑ 13-UNDER CARRIAGE I FIRE ❑ IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 15-OTHERDISTRACTED ❑ 0 U2 4 M M 2 4 ❑Y ❑SNEM N UNK VEH. 9 r AT CRASHD 9 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN = CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s. il 6 I,.4 COM VEH 0 0 3 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 10 7 ; _5 *If ves.See Sidebar U1 Z FA44649 IL 2026 E TELEPHONE IL D 4T1 BF3EK2BU600335 FIRST CHICAGO INS ❑Y N N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR113 m Elgin Fire 99 9 Same I LS 1134527-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 9 2 eu �{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 new 0 KCV 0 DV 1 9 9 7 Honda Accord 1998 oo-NONE 11-.. 12---0 DUE TO CRASH rg ❑ 2 x Ti Yr 13-UNDER CARRIAGE I FIRE ❑ N U2 M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,1,6•TOPO3 * X ❑Y ❑N N UNK VEH. AT CRASH 99-UNKNOWN 0istraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 1!:_. COM VEH 0 N U1 CO FIRST CONTACT 1 Y _, _6 •(ryes.See SidebarC H ELGIN IL 60120 0 1 0 FA76642 IL 2025 I 0 M IL D 1HGCG5656WA083995 ALTEZA INS ❑Y N N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire 99 9 Same 12RA000065319 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused ID RESPONDER Y ® 9 U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 E/ MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 06,04 ,2025 10 48 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 0 06 15 / ! ❑PM ❑Construction * 4 R 3 ❑ $I CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME ROLDAN PEREZ.JENNER. E. 11-802-A 295001457 / r ❑PM SLMT oN ® 11 1 0 •CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility r 2 ❑ 45 ARREST NAMEAM 7 1 / ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 295-Lazcano. Ramon 501 331-Ziegler 07 , 15,2025 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 T L I O r ----r••--, I _ Not To Scots - A CMV is defined as any nmtorDvehicl IOe used to transport passengers or property and: Z �N�D I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< t- }-- ''-- --' I r 0 INDICATE NORTH combination):or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver 73 and: L ��j-� _ (example:shuttle or charter bus):or X N �.y- 7774BIG711MBER?RD7ENT 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees In the course of their employment(example:employee 73 transporter-usually a van type vehicle or passenger car):or w } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N MORNINOSIDE70R & for direct compensation(example:large van used for specific purpose):or O L L____a.....t I i a - L 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). X/ m CARRIER NAME Z ADDRESS 0 u) 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------------ - USDOT NO. ILCC NO. Tn XI Source of above Z . 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 E D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No : 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 LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE