Loading...
HomeMy WebLinkAbout2025-00038310 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 I0 01 1 11111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *X003655124* u, 1 U2 1 1 1 U116 uz 1 U, 1 U2 U, 1 U2 1 1 9 U1 1 U221 *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 El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-0003831 O VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 06 16 2025 ®AM YES ®NO U1 -< KATHLEEN DR Elgin mo /day/yr 11.31 ❑PM FLOW CONDITION Ill 010(D!MI N E O W Pamela Dr COUNTY PROPERTY ❑Y 21 N DOORING Ely #OF MOTOR 0 SLOW 1 (n 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 O �i DRIVER t] PARKED l�DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROM TOWED U1 O Lo ez.Ana. M. 0 2 / yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn F 2 SYTM 5 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-U15-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it �i 4 COM VEH 0 Ea 1 0 ~ ELGIN I L 60123 B 1 0 FIRST CONTACT 1 7 . __5 *I(Yes.See Sidebar Ut Z V207974 IL 2026 Isui TELEPHONE IL D 3N1 CN7APOEL852915 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Gonzalez.Vincente 0498410-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV yr N_ ,y _1 ❑ 2 ,� o _ 13-UNDER CARRIAGE 10;I c. 2 FIRE 0 ® U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16 El -TOP 3 0 X a ❑Y N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value POINT OF s ) 4 U1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO F,,, FIRST CONTACT 7 O7 ,�=QI_5 •If Yes,See Sidebar S640128 IL 2025 99AR 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5FNYF3H57BB026537 State Farm ❑V ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Painter. Irma 3441335-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 3 06 / M 2 5 B 1 0 m / / #OCCS D / / UI 2 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 06,16 /2025 11 31 ®❑AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ., o" 2 0 28 99 / / ❑PM• ❑Construction >E N 3 0 Izi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Lopez.Ana. M. 11-601 S1547-000092 / / ID PM SLMT o N - ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility t 2 ❑ ARREST NAME AM 7 / / pM El Unknown work zone type 25 U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1547-Steele.Justin 602 407-Sproles 08 ,05/2025 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- i•-- -'-- --' r Not To Scale I - INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or 0 1 -----Th ll 1 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 L L.__-A-. I } } . transportingemployees in the course of their employment(example:employee N transportr-usually a van type vehicle or passenger car): r CO L L.___a.._..l I _ I. } } 1 •4. Is used or designated to transport between 9 and 15 passen including the driver, for direct compensation(example:large van used fors specific purose):or L L--_-a-.... UM. - i. < i. 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m rn Air urarww..nvor placarding(example:placards will be displayed on the vehicle) 11 CARRIER NAME Z > ADDRESS 0 1. i •—1 4°rl C )!I n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1; I ❑ Not in Comm./Govt. Not in Comm./Other _Y_ _ ; - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI 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 ❑ No 0 Unknown M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE