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HomeMy WebLinkAbout2025-00036024 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I0110110011 0 II H fl 11 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003846O77* u, 2 U2 1 1 1 U, 4 U2 1 U, 1 1_12 U, 1 U2 1 4 9 U1 1 U221 *P 0119* 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 ❑$501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00036024 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m 107 S CLIFTON AVE Elgin02:35 ® ❑ RELATED ❑Y ®N 06 06 2025 ®AM ❑YES ®NO U1 -< _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n ❑ FT,MI N E S W Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I &RUN ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 2 / yr 13-UNDER CARRIAGE ©10,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4 COM VEH 0 Ea 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 __5 *II Yes.See Sidebar U1 Z FB68132 IL 2025 E TELEPHONE IL D SALAE25498A445137 State Farm ❑Y ®N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m co Wall.Charles.J. 3467864-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER • RESPONDER 2 eu 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row yr 10 12 i 2 FIRE ❑ ® U2 1 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 0 ® SPDR n ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value U1 0 - POINT OF s I 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO F,,, FIRST CONTACT 6 O7 ,�=Q-405 •If Yes,See Sidebar C DR17248 IL 2025 0 N M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0 1 G 1 PD5SB8E7341183 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Castillo. Hadriaan 3432382-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 Aguilera.Jocelyn. P. Bushisisrubslhouse. 06/06 ,2025 02 27 ®❑AM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v 2 107 S CLIFTON AVE ELGIN IL 60123 28 99 , , ❑PM ❑Construction >E Z 3 0 Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME Wall.Wolfgang. M. 11-708 1552000093 , , ❑PM o U 1 ER1 1 1 lgiCITATIONS ISSUED ❑PENDING • UtilitySLMT u SECTION CITATION NO. ROAD CLEARANCE TIME AM 0 r 2 El ARREST NAME Wall.Wolfgang. M. 11-601-Ax 1552000092 06,06 ,2025 03 30 j PM ❑Unknown work zone type U1 25 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 El Am1552-Thompson.Ahmad Rashad 601 331-Ziegler 07 , 15,2025 01 30 El PM Workers present? ®N U2 25 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 . 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } } L._i ' ' Ili • INDICATE NORTH combination):or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n C - } (example:shuttle or charter bus):or X L A 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 X Bhutler78t transporter-usually a van type vehicle or passenger car):or co 111 4. Is used or designated to transport between 9 and 15 passengers,including (I) -- - } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m A CARRIER NAME Z .1.i'r _ ADDRESS 0D f' CITY/STATE/ZIP 0 -'^'' MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I _ ❑ Not in Comm./Govt. Not in Comm./Other •ll ?carton?Ave Not To Scale USDOT NO. ILCC NO. mXI Source of above z . 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 T. 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? ❑ Yes II No ElUnknown A 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: Arties . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGEEXTENT: Y/T6 DUE TO ® DISABLING DAMAGE NOT DAMAGE Arties 3 TOWED B VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE