HomeMy WebLinkAbout2025-00036114 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003246067i
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$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 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00036114 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
161 S EDISON AVE El 01:23
® ❑ RELATED ❑Y ®N 06 06 2025 ❑AM ❑YES El NO U1 -<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ 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®N ® FREE FLOW # LNS 0
Q83 DRIVER t] PARKED ❑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 C)
0 5 !
yr 13-UNDER CARRIAGE ) FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) NI
10 !O DISTRACTED 0 0 U2 2 rn
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i1 6 �i,4 COM VEH 0 0 1 0
~ E LG GIN I L 60123 0 1 0 FIRST CONTACT 2 7 :I -_5 *II Yes.See Sidebar Ut
Z FJ34281 IL 2026 E
TELEPHONE
IL D 0 1 G N E K13ZX3J 183624 State Farm ❑Y Il N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR .—
Same 2041998-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
D
Refused ❑Y ElN 2 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NUV 0 KCv 0 DV
yr Ford Explorer 2014 O 00-NONE O l t2'"_1 DUE TO CRASH 0 El Cgl® 2 x
I' 13-UNDERCARRIAGE 9( c 2 FIRE U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0
a ID NJ ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value
POINT OF 8 '4ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 O TA-1:..5 COM•IesVSee Sidebar❑ ® W
H FE17479 IL 2026 I0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FM5K8D87EGA10761 State Farm ❑V ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Aguilera. Erik 3224928-SFP-13 BAC
E
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)
1 6 07 / M 2 3 0 1 0
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/ / #OCCS D
/ / UI 2 D
/ / 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 06/06 /2025 01 23 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 ❑ 28 99 , / ❑PM• ❑Construction
1
Z3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
-, ® 11 1 ARREST NAME Luna-Barajas.Adan 11-601 1529-000413 , / El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N DI AM 30
t 2 El ARREST NAME Luna-Barajas.Adan 11-407-A 1529-000414 , / PM ❑Unknown work zone type U1
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1529-Audi red.Jonathan 601 07 ,01 ,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 CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }""-I""'1 S?Edlson?Ave. - INDICATE NORTH combination):or -I
® 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
< <_---------i ` }I } } transporting employee �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
161?S?Edison?Ave. C
-- -- } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
_ r ni for direct compensation(example:large van used for specific purpose):or O
i 'Er r'-'IN -ti
__ I,, I _ _ < < t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p I —I
CARRIER NAME Z
- _ ADDRESS 0
D
CITY/STATE/ZIP n
Not To Scale J I - i. MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Orange
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE