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HomeMy WebLinkAbout2025-00032996 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 l fl I Oil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003855O2S u, 1 U21 1 1 1 U110 U2 u, 1 1_12 1 u, 1 U2 1 4 9 u, 2 u221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00032996 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 �I ® ❑ RELATED ❑Y ®N 05 24 2025 IgIAM ❑YES ®NO U1 -< 415 SUMMIT ST Elgin00:30 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITI COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n ❑ FT/MI NESW Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER O PARKED El DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 O NAME(LAST,FIRST,M) Pu. Baltazar m0 D /3 13-UNDER CARRIAGE 10 , 2 FIRE ❑ al E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 II1f M 2 SY4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il B 4 COM VEH 0 j$J 1 0 ~ ELGIN IL 60120 0 1 0 FIRST CONTACT 12 7_; _5 *Irves.SeeSidebar U1 Z4189908B IL 2026 E TELEPHONE IL D 0 1 FT8W3BT3KEE19864 STATE FARM ❑Y ®N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 3644781-SFP-13 1 1- 5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 c 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV !1 9 yf 7 Chevrolet Traverse 2020 00-NONE It t2 (,-2 FIRE DUE o CRASH ® U2 2 cXj o 13-UNDER CARRIAGE El c ii M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOPS X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistraclIon Value 0 POINT OF 8 i1 it 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 5 7 —_,SOS •IfYes.See Sidebar MELROSE PARK IL 60164 0 1 0 CASTROF IL 2026 REAR 0 C Z IL D 1 G N EVG KW4L1138762 ALLSTATE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 975045606 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 O EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 5 05,24 l2025 00 20 ®❑pM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 08 06 I ! ❑PM ❑Construction * Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o 1 ® 11 5 ARREST NAME Pu. Baltazar 6-303-A S1924-000399 ! ! El PM SLMT 124 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility o N 0 AM T 2 ❑ ARREST NAME Pu. Baltazar 11-402-A S1924-0003 ) ! pM ❑Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1541-Wilkerson.Tondeo 300 331-Ziegler , ! ❑❑PM Workers present? ®N U2 10 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 -< ' }--__r-_--; } combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n _ } (example:shuttle or charter bus):or X Not To Scale I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O -- - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or co-- ~� - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y � . for direct compensation(example:large van used for specific purpose):or O c - a0 , L L____a____� l-' _ .. } .. < 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m l placarding(example:placards will be displayed on the vehicle). atpanan stuwar CARRIER NAME Z ADDRESS 0 = 7 CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn 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 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? ❑ Yes II No ElUnknown 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 71 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White Blue,Dark u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE