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HomeMy WebLinkAbout2025-00039483 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100000 lI DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003663458 u, 1 U21 1 1 1 U, 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00039483 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ R PRIVATE ELATED ❑Y ®N 06 20 2025 DAM ❑YES ®NO U1 ROUTE 20 Elgin mo /day/yr 06:33 ®PM FLOW CONDITION m 02540!MI NOS W Cookane Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) 0 2 ! yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 0 IN ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 j$J 1 O H I . BARTLETT IL 60103 0 1 0 FIRST CONTACT 12 7 . _s *If Yes.See Sidebar U1 ZFB83943 IL 2025 TELEPHONE IL D 0 1 FAHP3F29CL471016 None ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Delgado.Gines Tori. E. None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 XI g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NI ❑Ncv ❑Dv !2 0 0 1 ^ NAME(LAST,FIRST,M) De Leon.Ana Maria. R. Toyota Corolla 2025 00-NONE 10' 12 2 O CRASH 0 ® U2 C 2 ... mo a 13-UNDER CARRIAGE c,� FIRE c F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 POINT OF 8 i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QIOS •It Yes.See Sidebar C Hanover Park IL 60133 0 1 0 FE78490 IL 2025aR0 Si) IL D 0 5YFB4MDEXSP313043 Geico Secure ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 6118644290 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z N 1 ® 11 1 61 ,01 )025 06 33 ®pm in a Work Zone? ❑N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 03 28 1 1 0 PM ®Construction * Z3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Perez Delgado.Joel.J. 11-601 1512541 1 r El PM SLMT o U 1 ® 11 1 CITATIONS ISSUED 0 PENDING Utility o N SECTION •CITATION NO. ROAD CLEARANCE TIME AM• 0 t 2 El ARREST NAME Perez Delgado.Joel.J. 3-707 1512542 61 101 1025 07 00 0 PM El Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 1512-Juarez-Huichapan.Juan 400 81 , 12 ,25 01 30 ®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. A CMV is defined as for vehicle used to transportand: r ----,5-••--, ; any motor passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< - }----i-- --; } } } r - , ; ; , 1, ( combination):or —I INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (example:shuttle or charter bus):or X 3. Is L L.-_------ 1 i. <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or c0 F F----------I , F I- I- <--_-a-___� 1 , , , 4. Is used ordesi natedtotrans rt between 9 and 15 passengers,including C} for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L---------_.: L L L i.___-..i._ ; t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z i. ADDRESS 0 co , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 -Y- —4 , I- ; ; ; I. USDOT NO. ILCC NO. m 73 Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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? 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 Blue White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE