HomeMy WebLinkAbout2025-00037916 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 l lI
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003653E-S
u, 1 U21 2 4 1 U1 3 U2 1 U, 1 u2 1 U, 1 u2 1 1 15 U1 1 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 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00037916 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I
HIGHLAND AVE Elgin 01:44
0 0 RELATED ®Y ❑N 06 14 2025 ❑AM ❑YES ®No u1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W DAMISCH RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGED AREA(S) FRO T�TOWED U1 0Perez. Mariano.A. 0 4 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 0 m
M 2 8 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UUNKNOWN 9 16•TOP 3 `Distraction Value 7 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, ii_6 1,.4 COM VEH 0 g! 1 C)
F. FIRST CONTACT 12 7 ;—, _5 *IIYes.See Sidebar U1
Z Schiller Park IL 60176 B 1 0 AU77630 IL 2026 REAR
TELEPHONE
IL D 0 5LMFU27569EJ00138 Progressive ❑Y ISIN U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 929005688 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman 0 Y El 2 ou
rg-
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 NCV 0 DV
/1 9 9 0 Kia Motors Col(.parnival 2025 00-NONE ,0.1112 ._1 DUE TO CRASH D U2 2 C
.. 13-UNDER CARRIAGE III
c
M 2 8
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOPQ * X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 9 0
POINT OF S it �I COM VEH 0 ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �J 6
FIRST CONTACT 3 7_ _, _5 *It Yes.See Sidebar
H McHenry IL 60050 B 1 0 FF60535 IL 2026 REAR
0 N
D
IL D 0 KNDNC5K34S6537584 USAA ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Rocha. Rebecca. K. GIC 03220735 7101 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
1 12 03 /
LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 61 /41 /025 01 44 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 D 37 3 23 28 61 /41 /025 01 44
®PM• ❑Construction *
en
R O ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Perez. Mariano.A. 11-601 S1542-000299 61 /41 /025 01 52 Igi PM' 0Utility SLMT
ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 ❑ 37 2 ARREST NAME Perez. Mariano.A. 11-1204-B S1542-000300 61 /41 /025 02 59 ®PM ❑Unknown work zone type U1 45
2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1542-Chase. Ethan 901 71 / 51 /025 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.
. 0
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 -<
c ` -' -4. r INDICATE NORTH combination):or —I
' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ - } (example:shuttle or charter bus):or 0
A ® 3. is desgned to carry 15 or fewer passengers and operated by a contract carrier i O
- } } } transporting employees In the course of their employment(example:employee 73
Not To Scale I transporter-usually a van type vehicle or passenger car):or CO
i_ .:. .}----J. \. 1. } 1- 1- •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
�.: for direct compensation(example:large van used for specific purpose):or
L L____a____.: ..- ' _ t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71
placarding(example:placards will be displayed on the vehicle). XI
•, `i...- CARRIER NAME Z
�� ADDRESS O
'n
CITY/STATE/ZIP 0
/ni--1------..._._.....
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— --- "1 USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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? 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
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
White Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE