Loading...
HomeMy WebLinkAbout2025-00036694 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001101111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X46384,466 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202512025-00036694 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 ® ❑ RELATED ®Y 0 N 06 09 2025 E�IAM ❑YES ®NO U1 -< N MCLEAN BLVD Elgin09:48 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W ABBOTT DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NUV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n 0 4 / yr 13-UNDER CARRIAGE 1U l 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 IE 99 m M 2 SY5 ❑Y ONM DUNK VEH. 0 AT CRASH IN 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F. POINT OF & i�B 4 COM VEH 0 Ea 1 0 FIRST CONTACT 12 7_:— ___, _5 *II Yes.See Sidebar U1 Z GLENDALE HEIGHTS IL 60139 0 1 E798804 IL 2026 REAR TELEPHONE IL D 2HGFG3B82DH508144 STATE FARM ❑Y ®N U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 3506970SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 D Refused ❑Y ❑ N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUV 0 NCV 0 DV !1 9 6 8 Jeep(after 1911ngler 2016 00-NONE O. Q!'O DUE TO CRASH rg p 2 73 o yr ©-UNDER CARRIAGE 10( I E FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0 s i1 5 �i 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 11 7j 5 COIfYes.M• VEH See Sidebar❑ ® U1 W ZSLEEPY HOLLOW IL 60118 0 1 0 Q657264 IL 2025 I 0 N D IL D 1 C4BJWFG9GL216953 STATE FARM ❑Y ®N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 2930117SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPOND O N U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 co U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2 Z N 1 CD 11 4 61 ,12 r25 09 48 ❑PM in a Work Zone? NJ DIRP D 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 4 C1 0 T 2 0 2 99 ( , ❑PM, 0 Construction X R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 -a, ARREST NAME CHAVOLLA ZENDEJAS.ALBERTO 11-902 244001812 , r El Pm SLMT oN 1 ® 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility t 2 ❑ 30 ARREST NAME AM c- T ❑PM 0 work zone type U1 1 r ❑ 2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30 244-Blomberg. Michael 501 71 , 51 ,025 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••--, , I I ; 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 -< ` ` -'- -' 72 • INDICATE NORTH combination):or -I m I I N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r r (example:shuttle or charter bus):or 0 gI I Not To Scale. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O __ U I I - } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or co 73 } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N 1 ; ; for direct compensation(example:large van used for specific purpose):or I I i. . < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). X./ D ABBOTTTDR CARRIER NAME Z a ADDRESS 0 w mCITY/STATE/ZIP 0 C 2 _ MOTOR CARR.ID 0 Interstate ❑ Intrastate I I r I I ❑ Not in Comm./Govt. Not in Comm./Other U a USDOT NO. ILCC NO. m XI Source of above Z . own tank)? 0 Yes 0 No 0 Unknown 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? A ❑ Yes II El Unknown C 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 v 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. Z Black Silver 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE