HomeMy WebLinkAbout2025-00037543 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
011011000 l III
1110111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03853916
u, 1 U21 1 1 1 U1 2 U2 1 U1 1 U2 1 U, 1 U2 1 1 10 U, 4 u2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 12
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00037543 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ' V 0 N 06 12 2025 ❑AM ❑YES ®NO U1 —<
WOODARD ST Elgin06:18
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
gi50 !MI N E S W Hope Ct COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
® p Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM TOWED U1
NAME(LAST,FIRST,M) Gilmore.Allen.J. 0 mo /1
13-UNDER CARRIAGE 1U 1 • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®S NE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 4 COM VEH 0 Z?� 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1
Z FA15974 IL 2025 REAR
TELEPHONE
IL D 0 1 C4RJFAG9FC233210 American Alliance ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILAA101046500 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y ® N 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 WV 0 Nev 0 DV
!2 0 0 2 Honda Accord 2014 00-NONE 0. Qi'-_, DUE TO CRASH 0 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 El U2 C
Ti
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 11:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7� -_5 •If Yes.See Sidebar
H ELGIN Z IL 60123 0 1 0 542BNFY TN 2025 REAR
M
IL D 0 1HGCR2F38EA217220 NONE ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same NONE BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 06,12 l2025 06 18 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
T
Si 2 0
2 10 1 / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
a 1 ® 11 1 ARREST NAME Gilmore.Allen.J. 11-901-A S1519-000341 / ! El PM SLMT
I$!CITATIONS ISSUED ❑PENDING El Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM•
t 2 0 ARREST NAME Briceno Hernandez.Jose.G. 6-101 S1519-000342 061 12 /2025 07 30 ®PM ❑Unknown work zone type u1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1519-Bae2 a.Guadalupe 701 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
r combination):. Hasr more than pounds(example:truck or truckrtrarler
J 1. Has a weight rating10 000 -I
�,ra INDICATE NORTH o p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} wR+ - } r r r (example:shuttle or charter bus):or 0
L L.___A.-- fill 0 - I. } } 3. Is gemned toloaeesl5 or fewer in the course passengers
engermand operated by a contract:emplcarrier O
transporting employees ployment(example:employee 7
Not To Scale 1 transporter-usually a van type vehicle or passenger car):or w
L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
' Pe ( P 9 Pe or O
L L--_-a-....I - t 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). XI
—1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
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?El❑ Yes II No 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
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
Black Black
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 DUETO TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE