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HomeMy WebLinkAbout2025-00035430 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110011 010000000 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00384754S U111 U2 1 1 2 U116 U2 U1 1 U2 U1 1 U2 1 6 U1 1 U2 *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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00035430 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED PRIVATE ❑Y ®N 06 03 2025 ❑AM ❑YES ®No u1 -< RT20 WB Elgin mo /day/yr 01:29 ®PM FLOW CONDITION M OO 1C.'J!MI N E s © North Larkin Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW (A Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) 1 1 / yr Munoz.Gabriel.A. Honda Pilot 00-NONE ©1 O OUETOCRASH ® CIO 13-UNDER CARRIAGE D( 2 FIRE ❑ al E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �O DISTRACTED 0 ]Si U2 (T1 M 2 THER 4 ❑Y ®SYSNE❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN p9 '16-TOP •DistractionVatuc ALGN = 23 F CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRISTNTOONTACT 12 Q: QLFIOCIOMVSeeSV:ubar❑ U1 1 0 Z ELGIN IL 60120 B 1 0 W-331911 IL 2025 REAR TELEPHONE IL D 0 SFNYF4H48DB021802 Insurance American Freedo ❑Y ®N U2 (TI 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire 99 9 McKinney.Antoine 12244508700 2 r o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ❑ DRIVER 0 PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 Kcv 0 DV CIRCLE NUMBER(S) U1 yr 12 _ 71 o 13-UNDER CARRIAGE 10.i t, FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR 0 D Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA -5 C•IO e1sVEH See •Sidebar❑ ❑ C CO F` ---- C E co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)l(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 W 01 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ❑ 1 3 06,03 /2025 01 29 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8 453. T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,, 2 ® 43 3 18 99 1 + ) ❑PM. El Construction >F Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME / / ID PM o U 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 t 2 0 ARREST NAME 06/03 r2025 02 00 0 PM 0 Unknown work zone type U1 50 T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ - ❑AM Workers present? ❑ 1528 Rivera. Kevin sot , ❑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 truckrtrailer -< i- }--__r-_--; INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X I- ------;----; - transporting mployeened to slIn the course of 5 or fewer he r emplrs oyment example:employee a contract X } } } employment +M,,,- � a � transporter-usually a van type vehicle or passenger car):or � ' '^'"�a I. 4. Is used or designated to transport between 9 and 15 passengers,includingC }--- ----; '+�i., i - } } } g Po the driver, �� for direct compensation(example:large van used for specific purpose):or O %N.,. , < .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). XI 2# y~ CARRIER NAME Z C 0 ADDRESS �� D ` rn . CITY/STATE/ZIP n ._Nt. BO _ - i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- —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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Artier/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE