HomeMy WebLinkAbout2025-00037812 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00037812 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 06 14 2025 NAM ❑YES ®NO U1
ST CHARLES ST Elgin00:12
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
Egi50 !MI N E S W Elgin Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
® g Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NIAV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Valdez Hernandez. Pedro 0 7 /
yr 13-UNDER CARRIAGE 10.I , 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 SY5 ❑Y ON E DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 j$J 1 0
" �- SOUTH ELGIN IL 60177 0 1 0 FIRST CONTACT 12 T_; __s *IIYes.See Sidebar U1
ZFD11145 IL 2025 E
TELEPHONE
IL D 0 1 C3CDZAB1 DN599008 Allstate ❑Y N N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 802610028 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 5 2 XI
m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑row 0 Ncv ❑Dv
!1 9 9 9 Chevrolet Malibu 2020' 00-NONE ,t_' 12.._, DUE TO CRASH rg ❑ 2
o 13-UNDER CARRIAGE 101 2 FIRE ❑ N U2 C
II
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X
❑Y NiN ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractlonValue 9 g
POINT OF 8 4 COM VEH ❑ N Ut W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S �:'
FIRST CONTACT 6 4,. Q;__5 •If Yes,See Sidebar
ELGIN IL 60120 0 1 0 CK24653 IL 2025 REAR C
Z
IL D 0 1 G 1 ZG5ST9LF084739 Progressive ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 964181155 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 Public Works. Elgin Route 20 Sign 06,14 l2025 00 12 ®❑AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 1900 HOLM ES RD ELGIN IL 60123 20 99 , ! ❑PM ❑Construction >F
Z 3 ❑ N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. Et,45ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Valdez Hernandez. Pedro 11-601-Ax 752149 ! ! El PM SLMT
o N 1 ® 11 1 N CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
❑AM 30
F 2 El ARREST NAME Valdez Hernandez. Pedro 11-709-A 752125 1 ! ❑PM ❑Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1524-Silva.Jose 401 331-Ziegler , , ❑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
— _ WW1 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' 10 • INDICATE NORTH combination):or —I
8t.?Cn teaTSt ` BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i Urit?2 - (example:shuttle or charter bus):or 0
L A — 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). m
0
f ` CARRIER NAME Z
ADDRESS 0
):#Ekiln?Ave.
0
CITY/STATE/ZIP n
g
i._ i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
Not To Scale I <
�" Y USDOT NO. ILCC NO. m
XI
Source of above Z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Black
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE