Loading...
HomeMy WebLinkAbout2025-00040172 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 011110 0 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03864761 u, 1 U21 1 1 1 U1 4 U2 1 U, 1 1_12 1 U,99 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00040172 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 06 23 2025 ❑AM ❑YES ®NO U1 -< RT20 EB HWY Elgin mo /day/yr 03:40 ®PM FLOW CONDITION M 5 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 u) 23 FT/® N E S I© State St WITH VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM�TOWED VI E U1 0Gomez. Emmanuel. D. 1 1 / yr 13-UNDER CARRIAGE 10. 2 FIRE 0 NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 2 M M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 ALGN = ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S 4 COM VEH 0 Ea 1 0 F. Bartlett IL 60120 0 1 0 FIRST CONTACT 12 7_;1 __5 *II Yes.See Sidebar Ut ZX954238 IL 2026 REAR TELEPHONE IL D 1 NXBU4EE1AZ230452 Statefarm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Gomez.Ana. M. 0527257-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O Nov 0 Ncv ❑DV /1 9 6 6 Chevrolet Equinox 2022 00-NONE 10• t2 2 TO CRASH 0 ® U2 C 2 o 13-UNDER CARRIAGE (,- FIRE c M 2 4SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 9 0 X 0 Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .I. 4 COM VEH 0 ® Ut CO FIRST CONTACT 6 O7 ,�=EAR— •IfYes.See Sidebar C ELGIN IL 60124 0 1 0 DL754F IL 2025 i Si)0 IL D 2GNAXXEV1 N6102250 Zurich American ❑Y J N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Zeigler Chevrolet ADM7709708-06 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (MI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 01 / M 9 4 0 1 0 m / / #OCCS D / / UI 2 D / / 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 ,31 /025 03 42 ®AM 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 ❑ 28 03 / / 0 PM 0 Construction * Z 3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o El 11 1 ARREST NAME Gomez. Emmanuel. D. 11-601-Ax 1560000007 / / El PM SLMT - o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM t 2 0 ARREST NAME 61 /31 /025 04 45 ®PM 0 Unknown work zone type U1 55 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 55 1560-Jones. Bennett 701 81 / 12 /25 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 I ADDITIONAL UNITS FORMS. Rt.T20:Stste?St <—z 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 truckrtrailer -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X 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 73 transporter-usually a van type vehicle or passenger car):or CO L L.___a__._� 4. Is used ordesi natedtotrans rtbetween9and15 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 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D i placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z LRAM ADDRESS 0 ii T. CITY/STATE/ZIP C)0 _ 1 MOTOR CARR.ID 0 Interstate 0 Intrastate Not To Scale j ' i. i. i. 5 mow ❑ Not in Comm./Govt. ❑ Not in Comm./Other0 i. --- '-4 - USDOT NO. ILCC NO. C m Xi Source of above z . placards0 0 -I Were HAZMAT on vehicle? YesNo = If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI 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 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 'LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z ill TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 1 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