HomeMy WebLinkAbout2025-00039470 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 011011000 011
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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 15
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00039470 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
PRESTON AVE El In05:21
® ❑ RELATED ®Y 0 N 06 20 2025 12,— ❑YES El NO U1
g PRIVATE mo !day/yr ®PM FLOW CONDITION ITl
FTlMI N E S W CONGDON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN I�I 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!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROt T TOWED U1
Galdamez.Juan.J. 1 2 /
yr 13-UNDER CARRIAGE 2 FIRE ❑
10
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 I'T7
M 1 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1
Z FB68085 IL 2025 REAR
TELEPHONE
IL D 2G1WG5EK4B1283564 ALLSTATE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Galdamez.Jose. E. 8111900276 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
!1 9 8 8 Hyundai Elantra 2014 00-NONE 11 `'12' _, DUE TO CRASH gi p 2 x
... - 13-UNDER CARRIAGE FIRE ❑ El U2
M 1 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ON ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I 6 i',.4 COM VEH ❑ Eg Ut W
FIRST CONTACT 9 7 _, _5 •Iryes.See Sidebar C
m SOUTH ELGIN IL 60177 0 1 0 EB87100 IL 2025 I Si)0
D
IL D KM H DH4AE4EU086341 TRAVLERS ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 CHU. MICHAEL. H. 6149945872031 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
W 07 / F
m
/ / #OCCS D
/ / U1 1 D
/ / 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 4 61 )01 ,025 05 21 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 28 15 I / ❑PM ❑Construction *
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Galdamez.Juan.J. 11-1401 1563000006 r ! El PM SLMT
ulgi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
o N 0 AM 25
t 2 El ARREST NAME Galdamez.Juan.J. 11-407-A 1563000008 r r PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 20
1553-Jentsch.Clarissa 201 391-Jacobucci 81 r 12 r25 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 4101 r INDICATE NORTH comb rtatbn)or p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
i Not To Scale I - (example:shuttle or charter bus):or 0
i i i j 1 I t 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier I O
I- I- -A- -•i avpmM�. es pa g pe by
- } } } transporting employees in the course of their employment(example:employee X
unnzL transporter-usually a van type vehicle or passenger car):or
CO
L 4. Is used or designated to transport between 9 and 15 passengers,including N
-__ ----; t1. ,J - } } } g Po passen rs,indudi the driver,
F for direct compensation(example:large van used for specific purpose):or o
L L____a..... i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
• t i► placarding(example:placards will be displayed on the vehicle).
rI f __ . 1
uNt1 CARRIER NAME
Z
1 I t ADDRESS 0
n
II CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y____1 USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown 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
Xl
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
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
Gray Gray
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 Other/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE